Family and Social Services Administration
Forms
Authorizations/Approvals
- Prior Authorization Request - High Intensity Policy
- Request for Prior Approval High Intensity Services SF 54389
- Prior Approval Request Form SF51311 (fill-in)
- Final AT Policy and Form SF SF 50881
- Request for Authorization for Audiology Services SF 51930
Assessment Team
- Indiana First Steps Family Summary (Sample)
- Indiana First Steps Multidisciplinary Assessment Report (Sample Report)
- Documentation of Informed Clinical Opinion
Data Entry
- Data Entry Information Request SF 53507 PDF
Eligibility Determination
- Physician's Health Summary SF 51929
- First Steps Part C Eligibility Determination Statement SF 50054
- Documentation of Team Discussion SF 51928
Exit Summary
Exit Summary SF 51310 Exit Summary (Spanish) SF 51428
Family Information Update
- Family Information Update SF 51358 PDF
Intake
- First Steps Enrollment Form SF 54645
Income and Insurance
- Hoosier Healthwise Enrollment Checklist
- Private Medical Insurance Consent SF 51308
- Private Medical Insurance Supplement SF 51309
- Cost Participation Expenses Worksheet SF 51359
- Cost Participation Co-Payment Form SF 51361
- Family Information Update SF 51358
- Insurance Issue Form SF 54962
IFSP (Initial or Annual)
- Annual IFSP Checklist SF 51919
- Annual Preparation Checklist SF 53976
- Changes to the IFSP SF 51841
- Documentation of Team Discussion SF 51928
- IFSP Form SF 46514
- IFSP, Spanish versionInitial Contact Checklist SF 53977
- Outcome Review SF 51838
- Reason for Delay of IFSP, revised SF 51312
- Request for Authorization/Meeting Minutes SF 51839
- Service Coordinator Visit Checklist SF 53978
- Request for Change or Addition in Service with ED Team Response SF 54960
Six (6) Month IFSP Review Packet
- 6 Month (or other planned) IFSP Review Cover Sheet SF 51840
- Outcome Review SF 51838
- Request for Authorization/Meeting Minutes SF 51839
Changes to the IFSP Packet
- Service Change to the IFSP Checklist SF 51921
- Documentation of Team Discussion SF 51928
- Changes to the IFSP SF 51841
Progress Reports
- Progress Report Form 1 Outcome (Oct. 2011)
- Progress Report Form 2 Outcome (Oct. 2011)
- Progress Report Form 3 Outcome (Oct. 2011)
- Progress Report Form 4 Outcome (Oct. 2011)
- Progress Report Form Additional Outcome (Oct. 2011)
Referral
- Referral Form (sample)
Releases
- Documentation of Receipt of Rights/Consent to Proceed/Permission to Access SF 51842
- Authorization to Release and Share Medical Information SF 55164
- General Reciprocal Consent to Release and Share Information SF51675
- Electronic Database Release (CRO 1) SF 55163
- Provider Reciprocal Consent to Release and Share Information SF 47960
Termination
- Ongoing Record Termination SF 52001
Transfer to another County
Transition Forms
- Transition Plan Instructions
- First Steps Transition meeting Minutes SF 51674
- Individualized Family Transition Plan SF 51672
- Family Information Update SF 51358
- Request for Authorization for Transition Meeting / Transition Checklist SF 51670
- Transition Meeting Notification SF 51671
- First Steps 30 Month Notice to Local Educational Agency (LEA) SF 51673
Online Services
Top FAQs I Want To...
- Apply for or check the status of my Medicaid (health coverage), SNAP (food assistance) or TANF (cash assistance) benefits.
- Find a quality child care provider in my local area.
- Learn about home and community-based supports for the elderly.
- Learn about job assistance for people with disabilities.
- Seek help for a mental health issue or a drug, alcohol or gambling addiction.
