Tip for State-specific

Anyone can refer a child — you don't need a doctor's referral

Tip for State-specific

Early Intervention is free for evaluation; services may have a sliding-scale fee depending on the state

Tip for State-specific

Children with certain diagnosed conditions (e.g., Down syndrome) are automatically eligible

Maternal & Pediatriceasy

Early Intervention Referral (Part C)

State-specific · State Early Intervention programs (IDEA Part C)

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

Form Details

Total fields: 30
Auto-fillable: 20 (67%)
Time without BeneFill: 20 minutes
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Filled by: both
Frequency: one time
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

Contact your state's Early Intervention program

https://www.cdc.gov/ncbddd/actearly/parents/states.html

Each state has its own EI program — find yours through the CDC link.

🏢

Submit through your pediatrician's office or a local referral source

Doctors, parents, childcare providers, and others can make referrals.

🌐

Call your state's Early Intervention hotline

Many states have toll-free numbers for referrals. Anyone can refer a child.

Filing Deadline

Children must be under age 3 to qualify for Part C Early Intervention. Refer as early as possible — there is no minimum age.

Required Attachments

📎 Referral form (varies by state)
📎 Medical records or developmental screening results (if available)
📎 Parent/guardian contact information and consent for evaluation

Processing Time

The state must complete an initial evaluation within 45 days of referral. Services can begin before the evaluation is complete if parents consent.

What Happens Next

A service coordinator will be assigned and will schedule a multidisciplinary evaluation. If eligible, an Individualized Family Service Plan (IFSP) will be developed.

Tips for This Form

✓ Anyone can refer a child — you don't need a doctor's referral
✓ Early Intervention is free for evaluation; services may have a sliding-scale fee depending on the state
✓ Children with certain diagnosed conditions (e.g., Down syndrome) are automatically eligible
✓ If your child turns 3 during the process, they may transition to preschool special education (Part B)

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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.

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

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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.

School Entrance Health Form

State-specific (e.g., VA MCH213G) · State Departments of Health/Education

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.

Immunization Record / Certificate of Immunization

State-specific · State Departments of Health

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

Medication Administration Authorization (School)

District-specific · School districts

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

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Early Intervention programs (IDEA Part C) or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.