ECEP Information & Checklist Please complete all sections

Transcription

1 UNM Health Sciences Center 2300 Menaul Blvd. NE Center for Development and Disability Albuquerque, NM fax: Early Childhood Evaluation Program ECEP Information & Checklist Please complete all sections Name: Date of birth: Is the child currently receiving Early Intervention (EI) or services? Yes No If yes, please provide the following: Agency: Service Coordinator: Work cell phone: Work Mailing address: Office phone/extension: Fax: When did EI services begin? Which EI provider knows the family best? Phone: ECEP maintains a list of families who would like to be called if there is a last minute evaluation opening, due to a cancellation. Would the family like to be added to that list? Yes No Please ensure that the following forms, including this one, are completed as part of an ECEP referral: o Completed Referral to ECEP form (4 pages) o Completed Patient Registration form o Completed Consent to Treat form signed by legal guardian o Completed Race and Ethnicity form signed by legal guardian o Copy of Insurance/Medicaid card o Mailed/faxed Authorization to Request Health Information* form to: (Use fax cover sheet provided) o PCP or other provider name: Date sent: o PCP or other provider name: Date sent:

2 o Hospital where child was born: Date sent: *Please fax or mail the original Authorization to Request Health Information forms with legal guardian s signature to the provider and send ECEP a copy. o Please have all medical records sent to ECEP, including any birth records, vision/hearing information, or specialists. o Individual Family Service Plan (IFSP), if available o Previous developmental evaluation/assessments, if available. o If you are referring for Autism testing, the referral will not be accepted without including M-Chat results (Modified Checklist for Autism in Toddlers, Revised with Follow-up questions). If the child is not old enough for the M-Chat indicate when The M-Chat will be administered. o If child s primary caregiver is someone other than biological parent, include a copy of the Power of Attorney (POA) or court Ex Parte. Please feel free to attach any additional information that you would like to provide. ECEP bills insurance, however; there will not be any charge to the family for an ECEP evaluation if the insurance company does not pay. If you have any questions, please call ECEP at or ECEP Information and Checklist Form Revised 06/14/17

3 UNM Health Sciences Center Center for Development and Disability 2300 Menaul Blvd. NE Albuquerque, NM Phone: Early Childhood Evaluation Program (ECEP) Fax : (505) Referral to ECEP Please complete all sections REFERRAL INFORMATION Who is referring: Name and Relationship to Child Referrer's phone: Today's date: Service Coordinator Name: Service Coord. Phone/ CHILD'S INFORMATION Name: Date of birth: SS#: Home language: Sex: M F Other languages: Does the child have a sibling diagnosed with Autism Spectrum Disorder (ASD)? Yes No Pediatrician or Primary Care Provider: Phone: Fax: Address: Parents/Primary Caregivers: Are the Parents the legal guardians for this child? Yes *No *If no, please include Power of Attorney (POA) and/or copy of court Ex-Parte. 1. Name: Relationship: Primary language: Mailing address: Phone/s: / / Home Cell Work Legal Guardians, Foster Parents or Other Caregivers: 1. Name: Relationship: Primary language: Mailing address: Phone/s: / / Home Cell Work 2. Name: Relationship: Primary language: Mailing address: Phone/s: / / Home Cell Work 2. Name: Relationship: Primary language: Mailing address: Phone/s: / / Home Cell Work Is the Children, Youth and Families Department (CYFD), or other protective service agency, involved with the child or family? *Yes No *If yes, please provide the CYFD Social Worker or contact and have CYFD worker sign all consents and release forms. Name: Phone: Fax: ECEP Referral Form Revised 6/2017 page 1 of 4

4 Child's Name: Who lives in the home with the child? Name Age Relationship to Child Primary Language EARLY INTERVENTION / THERAPY PROVIDER INFORMATION Is the child currently receiving Early Intervention (EI) or any therapy services? Yes No If yes, please provide the following: Agency: Service Coordinator: Work Cell phone: Work Mailing address: Office phone/extension: Fax: Therapist Developmental Specialist Speech Language Pathologist Occupational Therapist Physical Therapist Nutritionist Hearing Specialist Vision Specialist Other: Other: Name Agency Phone Frequency Which EI/Therapy Provider knows the child best? When did EI or therapies first start? Date: ECEP Referral Form Revised 6/2017 page 2 of 4

5 CONCERNS / QUESTIONS Child's 1. Who is completing the Concerns / Questions section? Caregiver Provider 2. Check all boxes below that best describe the nature of your concern(s). Accidents / Injuries Family Stressors Premature / Complex Birth Asthma / BPD Feeding / Nutrition Prenatal Exposures Attention Head Trauma / Loss of Consciousness Sensory / Regulation Autism Spectrum Disorder Hearing Slow Physical Growth Behavioral Difficulties Medical Special Equipment Cognition (Learning, Thinking) Meningitis Speech / Language Ear Infections Motor (Coordination, Balance) Vision Epilepsy / Seizures Motor (Functional use of arms/legs) Other: 3. Please explain your concerns or questions in more detail. Please provide examples: 4. What do you hope to gain from this evaluation? MEDICAL / DEVELOPMENTAL INFORMATION *NOTE: Please have all medical records sent to ECEP, including any birth records, M-CHAT and vision/hearing information.* 1. Does the child have a vision or hearing condition? Yes No If yes, please describe: Please provide any vision and hearing records available, including reports from NMSBVI and NMSD. 2. Has the child had a vision screening? Yes No If yes, please send copy of results with referral. 3. Has the child had a hearing screening? Yes No If yes, please send copy of results with referral. 4. Has the child received an M-CHAT-R/F? Yes No If yes, please send copy of results with referral or include results in IFSP. 5. Does the child have a medical / behavioral / developmental diagnosis? Yes No For example: Fragile X, ADHD, seizure disorder, etc. If yes, please describe: 6. Does the child take medication? Yes No If yes, please describe: ECEP Referral Form Revised 6/2017 page 3 of 4

6 Child's Name: 7. When did the child first do the following: Rolled over Sat without help Crawled on hands and knees Walked without help Said single words Put two or more words together (e.g. green car) Talked in short sentences Age Not Yet Not Sure 8. What are the child's strengths? 9. What does the child enjoy? LOGISTICS Please have all medical records sent to: ECEP 2300 Menaul Blvd. NE, Albuquerque, NM Fax: Are you able/willing to come to Albuquerque for the evaluation? Yes No 2. Are you able/willing to come to a nearby city (1-2 hours away from your home) for the evaluation? Yes No 3. ECEP maintains a list of families who would like to be called if there is a last minute evaluation opening, due to a cancelation. Would you like to be added to that list? Yes No 4. If English is not the native language for yourself or your child, will an interpreter be needed for the evaluation? Yes No If yes, what language? 5. Please feel free to attach any additional information you would like to provide. 6. When submitting the referral, please use the form: Checklist for Referral to ECEP, to ensure you have fully completed the ECEP Referral packet. 7. If you have any questions, please call ECEP at or ECEP Referral Form Revised 6/2017 page 4 of 4

7 UNM D~~~lo~~ent and Disability UNM Medical Group, Inc. Patient Registration Form UNM MEDICAL GROUP, INC. Center for Development and Disability 2300 Menaul Blvd NE Albuquerque, New Mexico, Phone: (505) Fax: (505) PATIENT INFORMATION Patient's Name (Last, First, MI): DOB: Address: Phone: City: State: Zip: Patient's SSN: Sex: M F Patient's Employment Status: Occupation: Employer Name: Employer Phone: Employer Address: Address: PARENT / GUARDIAN (IF PATIENT IS A MINOR) Name: Relationship: Address: City: State: Zip: Phone: NEXT OF KIN / EMERGENCY CONTACT INFORMATION Next of Kin: Relationship: Address: City: State: Zip: Phone: REFERRING PROVIDER Provider/Agency Name: Phone/Fax: Address: INSURANCE INFORMATION Is patient covered under Medicare/Medicaid? (please circle )Yes / No Medicare/Medicaid #: If covered under Medicaid, which salud? (please circle) Molina / BCBS / Lovelace / Presbyterian Is patient covered under Insurance? (please circle) Yes / No If yes, please provide the following: Policy holder's Name: Policy holder's DOB: Policy holder's SSN: Relationship to Patient: Insurance Company: Phone: Address: Group #: Policy #: Policy holder's Employer: Authorization #: Occupation: Employer Address: City: State: Zip: Telephone: CDD 06/04/12

8 BBIRTH AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Patient Name: Date of Birth: Medical Record #: 1. I hereby authorize (Name of Disclosing Party) (Phone/Fax of Disclosing Party) (Address, City, State, Zip of Disclosing Party) To Disclose to: UNM Center for Reproductive Health UNM Center for Life 1701 Moon NE, Suite Jefferson Blvd. NE, Suite 100 Albuquerque, NM Albuquerque, NM UNM Cardiology Clinic McMahon UNM Truman Health Services 4824 McMahon Blvd NW, Suite Encino Place NE, Bldg F Albuquerque, NM Albuquerque, NM Please Fax Request to: UNM Center for Development and Disability UNM Vein and Cosmetic Center 2300 Menual Blvd NE 7007 Wyoming Blvd NE, Suite A-3 Albuquerque, NM Albuquerque, NM Please Fax Request to: UNM Dental Camino de Salud Residency Clinic 1801 Camino de Salud, Suite 1200 Albuquerque, NM UNM Dental Novitski Hall UNM Dental Camino de Salud Ambulatory 2320 Tucker NE Surgical Center Albuquerque, NM Camino de Salud, Suite Albuquerque, NM UNM Dental Carrie Tingley 1127 University Blvd, NE Albuquerque, NM Information to be disclosed: most recent visit/admission progress notes school records history & physical exam laboratory tests psychological evaluation initial assessment x-ray reports physical therapy evaluation consultation reports pathology reports speech & language evaluation operative report ER record/outpatient log occupational therapy discharge summary Billing Other (please specify) Covering the period(s) of healthcare: from (date) to (date) from (date) to (date) UNMMG C107 5/3/13

9 C ENTER FOR UNM Development and Disability UNM Medical Group, Inc. Patient Name: Date of Birth: Medical Record #: 3. I further authorize that this disclosure of health information will include information relating to (initial if applicable):. a. acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection, or other sexually transmitted diseases initial b. behavioral health services/psychiatric care initial c. treatment for alcohol and/or drug abuse initial d. genetic test results and related patient information initial 4. I understand that I have a right to revoke this Authorization at any time. I understand that if I revoke this Authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:. If I fail to specify an expiration date, event or condition, this authorization will expire in six months from the date on which it was signed. 5. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. 6. I understand that authorizing the disclosure of this health information is voluntary; that I can refuse to sign this Authorization and need not sign this Authorization to obtain health care treatment; and that if I authorize the disclosure of this health information, I have the right to examine and copy the information to be disclosed. A copy of this signed Authorization will be provided to me. Signature, Patient, or legal representative (Relationship to patient) (Date) Signature of Witness (Date) (Parent, if CPH/PFC&A patient over 14) (Date) PROHIBITION OF REDISCLOSURE: Federal regulations (42 CFR Part 2) and State laws (NMSA , 32A-6A-24, 24-2B-7 and ) prohibit further disclosure of mental health or alcohol and/or drug abuse treatment information, and of the results of tests for HIV/AIDS and other sexually transmitted diseases to any person or agency without securing another proper written authorization for that purpose, or as otherwise permitted by Federal regulations or State laws. UNMMG C107 5/3/13

10 PCP AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Patient Name: Date of Birth: Medical Record #: 1. I hereby authorize (Name of Disclosing Party) (Phone/Fax of Disclosing Party) (Address, City, State, Zip of Disclosing Party) To Disclose to: UNM Center for Reproductive Health UNM Center for Life 1701 Moon NE, Suite Jefferson Blvd. NE, Suite 100 Albuquerque, NM Albuquerque, NM UNM Cardiology Clinic McMahon UNM Truman Health Services 4824 McMahon Blvd NW, Suite Encino Place NE, Bldg F Albuquerque, NM Albuquerque, NM Please Fax Request to: UNM Center for Development and Disability UNM Vein and Cosmetic Center 2300 Menual Blvd NE 7007 Wyoming Blvd NE, Suite A-3 Albuquerque, NM Albuquerque, NM Please Fax Request to: UNM Dental Camino de Salud Residency Clinic 1801 Camino de Salud, Suite 1200 Albuquerque, NM UNM Dental Novitski Hall UNM Dental Camino de Salud Ambulatory 2320 Tucker NE Surgical Center Albuquerque, NM Camino de Salud, Suite Albuquerque, NM UNM Dental Carrie Tingley 1127 University Blvd, NE Albuquerque, NM Information to be disclosed: most recent visit/admission progress notes school records history & physical exam laboratory tests psychological evaluation initial assessment x-ray reports physical therapy evaluation consultation reports pathology reports speech & language evaluation operative report ER record/outpatient log occupational therapy discharge summary Billing Other (please specify) Covering the period(s) of healthcare: from (date) to (date) from (date) to (date) UNMMG C107 5/3/13

11 C ENTER FOR UNM Development and Disability UNM Medical Group, Inc. Patient Name: Date of Birth: Medical Record #: 3. I further authorize that this disclosure of health information will include information relating to (initial if applicable):. a. acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection, or other sexually transmitted diseases initial b. behavioral health services/psychiatric care initial c. treatment for alcohol and/or drug abuse initial d. genetic test results and related patient information initial 4. I understand that I have a right to revoke this Authorization at any time. I understand that if I revoke this Authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:. If I fail to specify an expiration date, event or condition, this authorization will expire in six months from the date on which it was signed. 5. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. 6. I understand that authorizing the disclosure of this health information is voluntary; that I can refuse to sign this Authorization and need not sign this Authorization to obtain health care treatment; and that if I authorize the disclosure of this health information, I have the right to examine and copy the information to be disclosed. A copy of this signed Authorization will be provided to me. Signature, Patient, or legal representative (Relationship to patient) (Date) Signature of Witness (Date) (Parent, if CPH/PFC&A patient over 14) (Date) PROHIBITION OF REDISCLOSURE: Federal regulations (42 CFR Part 2) and State laws (NMSA , 32A-6A-24, 24-2B-7 and ) prohibit further disclosure of mental health or alcohol and/or drug abuse treatment information, and of the results of tests for HIV/AIDS and other sexually transmitted diseases to any person or agency without securing another proper written authorization for that purpose, or as otherwise permitted by Federal regulations or State laws. UNMMG C107 5/3/13

12 EI AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Patient Name: Date of Birth: Medical Record #: 1. I hereby authorize (Name of Disclosing Party) (Phone/Fax of Disclosing Party) (Address, City, State, Zip of Disclosing Party) To Disclose to: UNM Center for Reproductive Health UNM Center for Life 1701 Moon NE, Suite Jefferson Blvd. NE, Suite 100 Albuquerque, NM Albuquerque, NM UNM Cardiology Clinic McMahon UNM Truman Health Services 4824 McMahon Blvd NW, Suite Encino Place NE, Bldg F Albuquerque, NM Albuquerque, NM Please Fax Request to: UNM Center for Development and Disability UNM Vein and Cosmetic Center 2300 Menual Blvd NE 7007 Wyoming Blvd NE, Suite A-3 Albuquerque, NM Albuquerque, NM Please Fax Request to: UNM Dental Camino de Salud Residency Clinic 1801 Camino de Salud, Suite 1200 Albuquerque, NM UNM Dental Novitski Hall UNM Dental Camino de Salud Ambulatory 2320 Tucker NE Surgical Center Albuquerque, NM Camino de Salud, Suite Albuquerque, NM UNM Dental Carrie Tingley 1127 University Blvd, NE Albuquerque, NM Information to be disclosed: most recent visit/admission progress notes school records history & physical exam laboratory tests psychological evaluation initial assessment x-ray reports physical therapy evaluation consultation reports pathology reports speech & language evaluation operative report ER record/outpatient log occupational therapy discharge summary Billing Other (please specify) Covering the period(s) of healthcare: from (date) to (date) from (date) to (date) UNMMG C107 5/3/13

13 C ENTER FOR UNM Development and Disability UNM Medical Group, Inc. Patient Name: Date of Birth: Medical Record #: 3. I further authorize that this disclosure of health information will include information relating to (initial if applicable):. a. acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection, or other sexually transmitted diseases initial b. behavioral health services/psychiatric care initial c. treatment for alcohol and/or drug abuse initial d. genetic test results and related patient information initial 4. I understand that I have a right to revoke this Authorization at any time. I understand that if I revoke this Authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:. If I fail to specify an expiration date, event or condition, this authorization will expire in six months from the date on which it was signed. 5. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. 6. I understand that authorizing the disclosure of this health information is voluntary; that I can refuse to sign this Authorization and need not sign this Authorization to obtain health care treatment; and that if I authorize the disclosure of this health information, I have the right to examine and copy the information to be disclosed. A copy of this signed Authorization will be provided to me. Signature, Patient, or legal representative (Relationship to patient) (Date) Signature of Witness (Date) (Parent, if CPH/PFC&A patient over 14) (Date) PROHIBITION OF REDISCLOSURE: Federal regulations (42 CFR Part 2) and State laws (NMSA , 32A-6A-24, 24-2B-7 and ) prohibit further disclosure of mental health or alcohol and/or drug abuse treatment information, and of the results of tests for HIV/AIDS and other sexually transmitted diseases to any person or agency without securing another proper written authorization for that purpose, or as otherwise permitted by Federal regulations or State laws. UNMMG C107 5/3/13

14 OTHER: Foster parents, Specialist, etc. AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Patient Name: Date of Birth: Medical Record #: 1. I hereby authorize (Name of Disclosing Party) (Phone/Fax of Disclosing Party) (Address, City, State, Zip of Disclosing Party) To Disclose to: UNM Center for Reproductive Health UNM Center for Life 1701 Moon NE, Suite Jefferson Blvd. NE, Suite 100 Albuquerque, NM Albuquerque, NM UNM Cardiology Clinic McMahon UNM Truman Health Services 4824 McMahon Blvd NW, Suite Encino Place NE, Bldg F Albuquerque, NM Albuquerque, NM Please Fax Request to: UNM Center for Development and Disability UNM Vein and Cosmetic Center 2300 Menual Blvd NE 7007 Wyoming Blvd NE, Suite A-3 Albuquerque, NM Albuquerque, NM Please Fax Request to: UNM Dental Camino de Salud Residency Clinic 1801 Camino de Salud, Suite 1200 Albuquerque, NM UNM Dental Novitski Hall UNM Dental Camino de Salud Ambulatory 2320 Tucker NE Surgical Center Albuquerque, NM Camino de Salud, Suite Albuquerque, NM UNM Dental Carrie Tingley 1127 University Blvd, NE Albuquerque, NM Information to be disclosed: most recent visit/admission history & physical exam initial assessment consultation reports operative report discharge summary Other (please specify) Covering the period(s) of healthcare: progress notes laboratory tests x-ray reports pathology reports ER record/outpatient log Billing from (date) from (date) UNMMG C107 5/3/13 to (date) to (date) school records psychological evaluation physical therapy evaluation speech & language evaluation occupational therapy

15 C ENTER FOR UNM Development and Disability UNM Medical Group, Inc. Patient Name: Date of Birth: Medical Record #: 3. I further authorize that this disclosure of health information will include information relating to (initial if applicable):. a. acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection, or other sexually transmitted diseases initial b. behavioral health services/psychiatric care initial c. treatment for alcohol and/or drug abuse initial d. genetic test results and related patient information initial 4. I understand that I have a right to revoke this Authorization at any time. I understand that if I revoke this Authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:. If I fail to specify an expiration date, event or condition, this authorization will expire in six months from the date on which it was signed. 5. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. 6. I understand that authorizing the disclosure of this health information is voluntary; that I can refuse to sign this Authorization and need not sign this Authorization to obtain health care treatment; and that if I authorize the disclosure of this health information, I have the right to examine and copy the information to be disclosed. A copy of this signed Authorization will be provided to me. Signature, Patient, or legal representative (Relationship to patient) (Date) Signature of Witness (Date) (Parent, if CPH/PFC&A patient over 14) (Date) PROHIBITION OF REDISCLOSURE: Federal regulations (42 CFR Part 2) and State laws (NMSA , 32A-6A-24, 24-2B-7 and ) prohibit further disclosure of mental health or alcohol and/or drug abuse treatment information, and of the results of tests for HIV/AIDS and other sexually transmitted diseases to any person or agency without securing another proper written authorization for that purpose, or as otherwise permitted by Federal regulations or State laws. UNMMG C107 5/3/13

16 Center for Development and Disability Consent to Treatment and Assignment of Benefits 1. I, the undersigned, hereby request an consent to medical treatment by the Center for Development and Disability or UNM Medical Group, Inc. and its physicians and staff (including administration of medication, tests and procedures) as deemed necessary. 2. I hereby assign and request payment directly to the Center for Development and Disability and UNM Medical Group, Inc. of any insurance or other authorized health benefits otherwise payable to me for medical treatment rendered, and to release any information required to the insurance company for consideration of payment for services. Signature of Patient or Representative Date Printe Name of Patient or Representative Relationship to Patient Revise 12/06/13

17 Dear Patient, UNM Medical Group Inc. wants to give you the best, safest health care possible! Your answers to these questions help us make sure we meet your needs and give the best, safest health care to all patients. Your answers will remain private. Access to this information is very restricted. Thank you! Do you consider yourself Hispanic or Latino? Yes No Don t want to answer What is your race? PICK ONE. American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White or Anglo Two or more races Don t want to answer If you do not speak English well, you have the right to a free interpreter. We will provide one for you. In what language do you prefer to talk about your health care? PICK ONE. English Spanish Vietnamese Navajo Other: In what language do you prefer to read about your health care? PICK ONE. English Spanish Vietnamese I need help with reading None Other: If you are American Indian/Native American, what tribe(s) or pueblo(s)? Navajo Pueblo: Other: Other: What is your religion or spirituality? Baptist Buddhist Catholic Christian: Jehovah s Witness Jewish Latter-Day Saints/Mormon Muslim Native Traditional Protestant: Other: None Don t want to answer What is your relationship status? Single Legally married Domestic partnership/civil union Partnered, living together Partnered, not living together Divorced/permanently separated Widowed/separated by death Other: Patient/Guardian signature Patient Name Date: Thank you! If you have questions, please ask our staff. (1) Enter data into Cerner, (2) Place reg sticker here (3) send form to ILS