Maternal & Pediatric Forms

Application for Children's Health Insurance Program for families with income too high for Medicaid but too low for private coverage. Uses MAGI-based financial eligibility. Children must be uninsured.

Referral for evaluation of infants and toddlers (birth to age 3) suspected of developmental delay. Includes consent for referral and release of health information.

Plan for managing health emergencies at school (anaphylaxis, seizures, asthma attacks, diabetic emergencies). Includes medication instructions and emergency contacts.

Medical documentation supporting the Individualized Education Program for children ages 3-21 with disabilities. Includes present levels, goals, accommodations, services, and placement.

Official record of required childhood vaccinations for school enrollment. Exemption forms (medical, religious, philosophical) vary by state.

Written plan for early intervention services for children birth to age 3 with developmental delays. Includes current levels of functioning, family concerns, expected outcomes, and services to be provided.

Parental consent for school district to bill Medicaid for IEP-related services (PT, OT, ST, nursing, psychological services).

Authorization for school nurse or designee to administer prescribed medication during school hours.

Enrollment of newborns in health insurance or Medicaid within required timeframes (typically 30 days from birth). Includes birth certificate information and parent coverage details.

Required for school entry. Includes immunization records, health history, physical examination, and developmental screening. Must be completed no earlier than one year before school entry.

Accommodation plan for students with health conditions (diabetes, allergies, asthma, ADHD) that impact school participation. Includes a medical management plan and emergency action plan.

Documentation of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for Medicaid-enrolled children. Covers developmental milestones, vision, hearing, dental referrals, and lead screening.

Application for WIC nutrition assistance providing education, breastfeeding support, and benefits for healthy foods. Requires proof of identity, address, income (or Medicaid/SNAP/TANF participation), and a health screening.

Medical documentation of nutrition risk factors qualifying an individual for WIC, such as anemia, underweight, or high-risk pregnancy.