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Referral/Intake
Intake Form Record of Access Form
Referral Status Form Release of Information Form
Surrogate Parent: Determination of Need Surrogate Parent, Eligibility Verification Form
Waiver of 45 Day IFSP Timeline Form
Waiver of 45 Day IFSP Timeline Form-(Spanish)

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

Evaluation
Informed Clinical Opinion Form Parental Prior Notice/Consent Form
Parental Prior Notice/Consent Form (SPANISH)

IFSP
Individualized Family Service Plan Individualized Family Service Plan (Spanish)
Medicaid Authorization for Part C services Medicaid Authorization for Part C services (Spanish)
Request for Primary Care Primary Service Provider Model
IFSP Team Considerations Private Health Ins Authorization for Part C services

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

Other
Birth to Three Listserv Service Provider Manual

Training:
Provider Goal Page Video Provider Goal Page Manual

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.