Birth to Three Logo

Referral/Intake
Intake Form Record of Access Form
Service Coordinator Map
Referral Status Form Release of Information Form
Surrogate Parent: Determination of Need Surrogate Parent, Eligibility Verification Form

Screening
Consent to Screen Form Consent to Screen Form (Spanish)

Evaluation
2018 Prior Written Notice 2018 Prior Written Notice (Spanish)
Consent to Evaluate Consent to Evaluate (Spanish)
Informed Clinical Opinion Form

IFSP
2018 IFSP Meeting Notice Invitation 2018 IFSP Meeting Notice Invitation (Spanish)
Medicaid Authorization for Part C services Medicaid Authorization for Part C services (Spanish)
Private Health Ins Authorization for Part C services Individualized Family Service Plan

Transition
Inactive File Notification Form School District Notice to Parents Template
Transition Referral Form

Billing
Medicaid Billing Manual Medicaid Code and Rate Chart
Medicaid Training Travel Time Reimbursement Tips
Travel Time Quick Sheet Request for Primary Physician Approval

Other
Birth to Three Listserv Physicians' Guide
Video Recording EI Sessions Form

Training
Information coming soon

Contact

If you have questions, or would like to schedule screening, contact:
South Dakota Department of Education
South Dakota Birth to Three
800 Governors Drive, Pierre, SD 57501
605-773-3678, 800-305-3064.