On this page, you can find examples of referral forms that are compliant withfederal Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act(FERPA) privacy and confidentiality requirements, feedback forms to inform primary care providers of the results of evaluations, and referral guidelines. The map shows states that have standardized referral forms.
States with Standardized Referral Forms
Developmental screening, referral for further evaluation, and ongoing interventions and services require coordination among primary care providers, specialists, early care and education providers, early intervention and special education programs, and families to ensure children and families receive appropriate services and do not fall through the cracks. Referral and care coordination require appropriate tools, such as referral forms, feedback mechanisms, and methods of communication among the providers and agencies serving children and families. Many states have developed tools and models for coordinating care, and others will continue to develop care coordination and integration systems using federal resources like the Integrated Care for Kids (InCK) Model (additional NASHP resources on integrated care for children are found here).
Has standardized referral form (37)
No known form (14)
* Note: Washington, DC is not pictured on the map, but is included in the counts above. It has an education provider referral form to Part C Early Intervention; English and Spanish versions available. English Form. Spanish Form. Found on this page.
37 states (including Washington, DC) have a standardized referral process to facilitate children and families accessing follow up services after identification of need, compared to only 14 in 2016.
Most states have forms specific to Part C Early Intervention referrals. Forms in 7 states (Arizona, Colorado, Connecticut, Georgia, Minnesota, Oregon, and Vermont) can refer children to a variety of services, including early intervention.
Referrals in 12 states can now be made online (Arizona, Arkansas, Idaho, Indiana, Maine, Michigan, Minnesota, Missouri, Montana, Ohio, South Carolina, and Tennessee)
17 states (Colorado, Hawaii, Illinois, Iowa, Kansas, Maryland, Minnesota, Montana, Nevada, New Mexico, North Carolina, Oregon, Texas, Vermont, Virginia, Washington, DC, and Wisconsin) have a form that enables referral feedback to be sent back to the referring provider.
11 states (Arizona, Arkansas, Colorado, Connecticut, Delaware, Missouri, Montana, North Carolina, South Carolina, Texas, and Vermont) have forms for use by a specific type of provider, such as primary care, child care, education, or a state department of human services.
4 states (Arizona, Colorado, Oregon, and Washington, DC) have a standardized form available in Spanish.
This information is based on a 2020 NASHP environmental scan. Please email Rebecca Cooper with any updates.
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