early start intake application packet...intake application . rcoc #147 es – rev. 8/20 page 1 of 4...

Early Start Intake Application Packet Birth to 3 years of age

Contents Instructions ........................................................................................................................................................................ 2

Application ..................................................................................................................................................................... 3-7

Authorization for Release of Medical Information ............................................................................................. 8

Notice Regarding Use of Private Insurance and Public Funding Sources ................................................. 9

Requesting Coverage from a Health Plan for a Child .............................................................................. 10-11

Consent for Evaluation ............................................................................................................................................... 12

Consent for Exchange of Information .................................................................................................................. 13

Parent’s Rights: An Early Start Guide for Families ...................................................................................... 14-15

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I N S E R V I C E T O P E O P L E W I T H D E V E L O P M E N T A L D I S A B I L I T I E S

Early Start Application Instructions Page (Birth to 3 years of age)

The Early Start Program is provided Under Part C of IDEA. California’s Early Start program focuses on the health, development, and well-being of children birth to 35 months, who have a delay in development, high risk factors, or have an established risk condition resulting in a developmental disability.

Eligibility Criteria: This application will assist the Regional Center of Orange County (RCOC) with initiating the next step of determining eligibility for the Early Start Program. Eligibility for Early Start services is as follows:

• Established Risk Condition: An established risk condition exists when an infant ortoddler has a condition of known etiology which has a high probability of resulting in adevelopmental delay.

• Developmental Delay: The child has a 33% delay in one or more of the following areasof development: Gross Motor, Fine Motor, Communication, Cognitive, Social/Emotional,and Adaptive/Self-Help.

• High Risk: An infant or toddler with a combination of two or more factors that requiresearly start services based on evaluation and assessment.

o High Risk for developmental disability also exists when a multidisciplinary teamdetermines that the parent of an infant or toddler is a person with a developmentaldisability and the infant or toddler requires early start services based on evaluationor assessment.

Eligibility Process: In order to complete the eligibility process, RCOC may authorize an evaluation to assess your child’s developmental levels and complete a review of your child’s medical history/records. The Early Start eligibility process may take up to 45 days.

Application Instructions: 1. Early Start Application: Review and complete as thoroughly as possible. (Family must residein Orange County)2. On the following four forms, fill in name of applicant, date of birth, initial and sign whereappropriate:

• Early Start of Orange County Consent for Evaluation• Early Start Orange County Consent for Exchange of Information• Authorization for Release of Medical Information Medical Records• Regional Center Early Start Program Notice Regarding Use of Private Insurance

The Early Start Application will be completed when: 1. All the information fields have been filled out accordingly.2. All the consent forms have been completed and signed.3. All the completed information has been submitted via one of the following options:

• Email: [email protected] • Fax: (714) 796-5200• US Mail: Regional Center of Orange County

Attention: Intake DepartmentP.O. Box 22010, Santa Ana, CA 92702-2010

mailto:[email protected]

EARLY START INTAKE APPLICATION

Page 1 of 4 RCOC #147 ES – Rev. 8/20 Early Start Intake Application

CHILD’S INFORMATION Please provide information regarding the child being referred First Name Middle Name Last Name

Date of Birth Gender ☐ Male ☐ Female

Address City Zip Code

Primary Phone Number Preferred Language Other Languages Spoken

Social Security Number Birth Mother's Maiden Name (if applicable)

Ethnicity ☐ American Indian or Alaska Native ☐ Asian ☐ Black/African American ☐ Hispanic/Latino☐ Native Hawaiian or Pacific Islander ☐ White ☐ Other (please specify)

Who does the child live with? ☐ Both Parents ☐ Mother Only ☐ Father Only ☐ Joint Custody ☐ Foster parent ☐ Other (please specify)

If the child has a Social Worker please provide the Social Worker’s Name, Phone Number, and Email Address

PARENT’S INFORMATION First Name Last Name

Date of Birth and Birthplace Relationship to Child


Primary Phone Number Secondary Phone Number Email Address

Preferred Language Other Languages Spoken

☐ Married ☐ Single ☐ Disabled ☐ Retired ☐ DeceasedEducation Level Occupation

Ethnicity

PARENT’S INFORMATION First Name Last Name

Date of Birth and Birthplace Relationship to Child


Primary Phone Number Secondary Phone Number Email Address

Preferred Language Other Languages Spoken

☐ Married ☐ Single ☐ Disabled ☐ Retired ☐ DeceasedEducation Level Occupation

Ethnicity

Date

Name of person completing this application

Relationship to child

Name of Birth Hospital and City, State

of 4 RCOC #147 ES – Rev. 8/20 Early Start Intake Application

If the child does not reside with biological parents, please complete Guardian/Foster Parent Name Language(s) Spoken

Phone Number Relationship to Child

EMERGENCY CONTACT A person we can contact if we are unable to contact parent(s)/guardian listed above. Name Language(s) Spoken

Phone Number Relationship to Child

SIBLING INFORMATION Please list the child’s brothers and sisters in the order of birth (including adopted/step-siblings) First Name Last Name Date of Birth Lives at

Home? Remarks (e.g. special education, health problems, step-sibling, currently receiving RCOC services)

INSURANCE/COMMUNITY RESOURCES If available, please attach a copy of the child’s medical insurance card(s) with this application. This is required by California Law.

☐ Yes ☐ No CalOptima/Medi-Cal Health Plan Name CIN #

☐ Yes ☐ No Private Insurance Health Plan Name Member #

☐ Yes ☐ No California Children’s Services (CCS) Member #

FAMILY HEALTH HISTORY Please review and check any that apply to the child’s family, explain any items checked ☐ Family’s health history unknown☐ Alcohol/Drug use ☐ Autism ☐ Birth Defect ☐ Cerebral Palsy☐ Emotional/Behavioral problem ☐ Genetic Condition ☐ Hearing/Vision ☐ Intellectual Disability☐ Learning Disability ☐ Mental health ☐ Neurological Condition ☐ Seizures/EpilepsyOther

MOTHER’S PRENATAL HISTORY ☐ Prenatal history unkown Total pregnancies Total miscarriages Total stillbirth

Which pregnancy was this child? Trimester prenatal care began How old was mother when the child was born? How old was father when the child was born?

Prenatal tests done during this pregnancy ☐ AFP/Triple Marker ☐ Amniocentesis ☐ CVS ☐ Non-stress test ☐ Stress test ☐ Ultrasound

MEDICAL CONCERNS DURING THIS PREGNANCY ☐ Anemia ☐ Bleeding ☐ Cytomegalovirus ☐ Diabetes ☐ Emotional stress☐ German Measles ☐ Heart Disease ☐ Herpes ☐ High Blood Pressure ☐ Infections☐ Injuries ☐ Kidney/bladder ☐ Rh Problem ☐ Toxemia ☐ Vomiting☐ Over-the-counter

Medications☐ Prescription

Medications☐ Recreational Drugs ☐ Smoking (type/how

many/day) ☐ Alcohol (amount/how often)

Describe

Email Address

☐ Child has no medical insurance


LABOR & DELIVERY Hours in Labor _______ Please describe if there were any problems during labor & delivery

☐ Spontaneous ☐ Vaginal ☐ Head First ☐ Forceps/Suction ☐ Single Birth☐ Induced ☐ Cesarean Section ☐ Breech ☐ Multiple Birth

BIRTH HISTORY

Birth Weight Length Apgar Scores (at 1 min and 5 min)

☐ No problems at birth ☐ Full Term (38-40 weeks) ☐ Premature # weeks ______ ☐ Length of stay in hospital ______☐ Cord around neck☐ *Breathing problems

☐ Seizures☐ *Resuscitation needed☐ Brain bleed ☐ Jaundiced

☐ *Didn’t cry immediately☐ *Birth Defects

*Please explain further

CHILD’S HEALTH/DEVELOPMENTAL HISTORY Check all significant health concerns/illnesses the child has had ☐ Allergies ☐ Anemia ☐ Asthma ☐ Autism ☐ Cerebral Palsy☐ Cytomegalovirus ☐ Ear infection ☐ Encephalitis ☐ GI disease ☐ Genetic Diagnosis☐ Head injury ☐ Hearing ☐ Heart defects ☐ Herpes ☐ Kidney/bladder☐ Meningitis ☐ Neurological ☐ Orthopedic ☐ Respiratory ☐ Seizures/convulsions☐ Surgeries ☐ Tuberculosis ☐ VisionOther

MEDICATIONS Please list all medications the child is currently using Medication Reason for Medication

SPECIAL EQUIPMENT & AIDS Check all items that the child is currently using ☐ Apnea monitor ☐ Colostomy ☐ Gastrostomy tube ☐ Hearing Aids ☐ Ileostomy☐ Nasogastric tube ☐ Oxygen ☐ Positioning ☐ Splints, casts, braces ☐ Suction☐ Tracheostomy ☐ Ventilator ☐ WheelchairOther


DEVELOPMENTAL HISTORY/CONCERNS Current Weight Current Height

Feeding Information/Concerns ☐ No concerns ☐ Current concerns ☐ Past concerns ☐ Doctor has concerns with weight/feeding☐ Chokes ☐ Gags ☐ Pockets ☐ Avoidance of certain textures☐ Vomits ☐ Food has to be pureed ☐ Food has to be in small bites ☐ Other☐ Breast Fed; how long? ___________________ ☐ Bottle Fed; how long? ___________________Examples of foods child can eat

At what age (in months) did the child do the following things? Held head up Crawled Said first word Rolled over Stood alone Used 2-3 word phrases Sat alone Walked alone What assistance are you seeking for your child?

Any evaluations completed, scheduled, or referred ☐ Physical ☐ Occupational ☐ Speech ☐ Feeding ☐ Behavioral ☐ Other

Do you have any social-emotional/behavioral concerns? If yes, please describe

PHYSICIAN CONTACT INFORMATION Please list pediatrician and any other specialists (e.g. neurologist, geneticist, etc.) Name and Specialty Address and Phone Number Date of last visit and reason

HOSPITALIZATIONS (excluding the birth hospital which must be included on page 1) Name of Hospital Address and Phone Number Dates of Hospitalization

OTHER (e.g. speech therapist, psychologist, physical therapist, occupational therapist, nurse, etc.) Name Address and/or Phone Number Date of last visit and reason

EARLY START INTAKE APPLICATION

RCOC #147 ES – Rev. 8/20 Early Start Intake Application

Please insert a recent picture of the child here(click the box to select a digital picture)

Date picture was taken

Child’s Name

Date of Birth


AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

RE: Date of Birth: UCI#:

I, the undersigned, hereby request and authorize any physician, hospital, medical clinic, health care service plan, contractor, medical group, independent practice association, medical service organization or other provider of health care who has rendered health care services to the above-named individual (hereinafter referred to as the “Patient”) to release to the REGIONAL CENTER OF ORANGE COUNTY (“RCOC”) any and all medical information in its possession pertaining to the Patient’s medical history, mental or physical condition or treatment, including:

ALL MEDICAL REPORTS, RECORDS, CHARTS AND NOTES, DOCTOR REPORTS AND NOTES, EXAMINATION RECORDS, X-RAYS, FILMS AND REPORTS, DIAGNOSTIC TEST REPORTS, LABORATORY REPORTS, PHYSIOTHERAPY RECORDS, PHOTOGRAPHS AND CHARTS, BILLING, EXPENSE, FEE AND COST RECORDS, COMPLETE HOSPITAL RECORDS, EMERGENCY CARE RECORDS, INPATIENT AND OUTPATIENT CHARTS AND RECORDS, RADIOLOGICAL REPORTS, MRI AND CT SCANS, PHOTOGRAPHS, NURSING REPORTS AND CHARTS, ALL DAILY RECORDS AND LOGS, DISCHARGE SUMMARY, STAFF AND CONSULTING NOTES AND REPORTS, SUMMARY AND ABSTRACT OF RECORDS AND REPORTS, INSURANCE DOCUMENTS, INCLUDING SIGN IN SHEETS, AND ANY OTHER MEDICAL RECORDS PERTAINING TO THE CARE, TREATMENT AND EXAMINATION OF THE PATIENT, REGARDLESS OF TREATMENT DATE AND REGARDLESS OF WHETHER OR NOT THE PATIENT IS STILL LIVING.

This request for disclosure of protected health information to RCOC is made at the request of the Patient for purposes defined herein. Authorization for release of the above-described medical information and records is granted specifically for the purpose of RCOC’s review, investigation and evaluation of its provision of services, pursuant to the Lanterman Developmental Disability Services Act (Welfare & Institutions Code §4500 et seq.) and Title 17, California Code of Regulations, §50201 et seq.

RCOC is a non-profit California corporation that, under contract with the State of California Department of Developmental Services, is one of several approved and statutorily mandated regional centers established for the purpose of providing services to persons with developmental disabilities.

I understand that only RCOC is authorized to receive the medical information requested to be released by this authorization. I understand that there may be some circumstances where my information disclosed to RCOC, pursuant to this authorization, may be subject to redisclosure without my consent if authorized by state or federal law. For example, RCOC may disclose my information for statistical research necessary to ensure the adequacy of our programs.

I understand that a covered entity (that is a health care provider who has information about you) may not condition treatment, payment, enrollment or eligibility of benefits on whether I, as the patient or legal representative, sign this form.

This authorization is effective immediately. I understand that I may revoke this authorization in writing at any time. This authorization shall terminate one year from the date of execution absent express revocation in writing. The provider of health care, health care service plan, or contractor, as described above, is no longer authorized to disclose the medical information and records requested herein one year from the date of execution of this authorization.

Photocopies/facsimile copies of this authorization shall be considered valid as the original. I further understand that I have a right to receive a copy of this authorization upon my request. I authorize RCOC to use the medical information described in this release.

Date Signature of Parent or Guardian or Legal Representative if Patient is a Minor or Incompetent

Relationship to Patient

Web Form RCOC # 148A – Rev. 4/13


REGIONAL CENTER EARLY START PROGRAM

NOTICE REGARDING USE OF PRIVATE INSURANCE

AND PUBLIC FUNDING SOURCES

Mailing Address: P. O. Box 22010, Santa Ana, CA 92702-2010 Telephone 714-796-5100 (24 hrs) * Toll Free 800-244-3177 * www.rcocdd.com

Web Form RCOC #704 ES - Rev. 6/13 Notice Regarding Use of Private Insurance

Name: UCI #:

DOB:

California State Law and Regulation (California Code of Regulations, Title 17 sections 52109 a & b) states that regional centers shall be the payer of last resort for required early intervention services after all public sources for payment have been considered. This includes California Children Services, MediCal/CalOptima, school districts or other public agencies that may have responsibility for payment. In addition, effective July 28, 2009, Title 14, Government Code Section 95004 (b) (1) California Early Intervention Services Act was amended to require the use of a family’s private insurance for early intervention services. A family’s private insurance must now be used for early intervention services that are determined to be medical in nature and are specified on a child’s Individualized Family Service Plan (IFSP). Parents who experience difficulty in accessing their private insurance or a health care service plan due to financial hardship, a projected increase in the cost of insurance or issues related to a lifetime cap should consult their RCOC Service Coordinator. RCOC does not want insurance co-payments, to become a barrier to the receipt of early intervention services of a medical nature. Evaluation and assessment necessary to determine eligibility for Early Start are provided at no cost to the family through regional center funding. I acknowledge that I have been informed of the requirement to use public sources of funding and

private insurance up to and including appeal of a denial* prior to use of regional center funds in the

Early Start Program.

_______________________________

Signature of Parent/Legal Guardian Date

_______________________________

Witness Date

c: Consumer File * Please see attached “Requesting Coverage from a Health Plan for Speech, Occupational and Physical Therapy for a Child” for assistance in accessing and appealing private insurance.


Requesting Coverage from a Health Plan

for Speech, Occupational and Physical Therapy for a Child The California Department of Managed Health Care requires your health plan to provide speech, occupational and physical therapy to your child if it is medically necessary. Your health plan is prohibited from excluding children with a developmental delay or specific diagnoses from receiving these therapies. This document offers guidance to parents who wish to request coverage under their health plan for speech, occupational or physical therapy for their son or daughter. The information applies to health plans that are regulated by the Department of Managed Health Care (DMHC). These include all Health Maintenance Organizations (HMOs) in California as well as two Preferred Provider Organization (PPO) plans offered by Anthem Blue Cross of California and Blue Shield of California. If you would like to speak to another parent for assistance obtaining information about your insurance coverage, please feel free to contact the RCOC Comfort Connection Family Resource Center at (714) 558-5400. What therapies does my health plan cover? You can find out what benefits are covered or excluded by your health plan in a document called the Evidence of Coverage, or EOC. You should receive an EOC from your employer or directly from your health plan on an annual basis. If you do not have one, you should request a copy. These documents may also be available on your health plan’s Web site. Health plans are generally required to cover basic health care services that are medically necessary. Since speech, occupational, and physical therapies are basic health care services, they should be covered by your health plan if they are medically necessary for your child. Until now, many California health plans have specified that these therapies are covered only for the purposes of rehabilitation. Typically, this means that if a health plan member suffers an event such as a stroke or traumatic head injury, these therapies may be provided to return him to his previous level of functioning – i.e., to rehabilitate him. For a child with a developmental delay, the purpose of these therapies is typically not rehabilitative since they would be intended to help the child develop new skills. The Department of Managed Health Care (DMHC) which regulates a majority of health plans in California has made the decision that health plans will no longer be allowed to categorically exclude speech, occupational, and physical therapies for children or set arbitrary limits on the number of sessions, since these services qualify as basic health care services. The DMHC has instructed health plans to change their Evidence of Coverage (EOC) documents to make it clear that these therapies are available to children when medically necessary. What does this mean for me and my child? If you believe your child needs speech, occupational, or physical therapy you should request an assessment for that therapy from your health plan. The health plan is obligated to do an assessment.

Adapted from Harbor Regional Center Page 2 of 2 Web Form RCOC #705 ES - Rev. 12/10

If the assessment determines that your child needs therapy, the health plan must provide it. Once services have begun, however, the health plan may periodically evaluate your child’s progress in therapy to see if continuation is warranted – in other words, to determine if the services continue to be medically necessary. (This is referred to by health plans as a “utilization review” process). What should I do if my health plan refuses? If you request speech, occupational, or physical therapy for your child and the health plan refuses to provide it, you should appeal that decision with your health plan. Information on how to appeal will be included in the letter that you receive informing you of the health plan’s decision not to cover the therapy. Generally, a health plan must respond to your appeal within 30 days. If they deny your appeal or if you have not received a response to the appeal within 30 days, you may request an Independent Medical Review (IMR) from the Department of Managed Health Care. Information about the IMR process and how to get help is available at www.healthhelp.ca.gov or by calling 1-888-466-2219. The letter informing you of the denial of your appeal should also include information about the IMR process. The Department of Managed Health Care regulates all HMO plans and two PPO plans provided by Anthem Blue Cross of California and Blue Shield of California. If your health plan is a “point of service (POS)”, an “exclusive provider organization (EPO)”, or a “Preferred Provider Organization (PPO)” other than Anthem Blue Cross of California or Blue Shield of California, it is not regulated by DMHC. Such plans also offer an independent medical review process, but it is provided through the California Department of Insurance. You may call 1-800-927-4357 or visit their Web site, www.insurance.ca.gov. If you believe your child needs Speech, Occupational and/or Physical Therapy you should: Ask your health plan to provide the service to your child. If you are told that the services are

not medically necessary, ask for your child to be assessed. If the health plan denies your request for an assessment or for the service, you should appeal

the denial. Information about how to appeal will be included in the letter informing you of the denial.

If the health plan denies your appeal or does not respond to your appeal within 30 days, you

should request an independent medical review (IMR) from the Department of Managed Health Care. Information about the IMR process will be included in the denial letter. You can also obtain information about the process at www.healthhelp.ca.gov or by calling 1-888-466-2219.

If the health plan authorizes one of these therapies for your child they may do a periodic

assessment of his or her progress to see if the treatment continues to be medically necessary. Some companies “self-insure” to provide health coverage to their employees. (Your human resources department can tell you if your employer is self-insured.) These plans are regulated under federal law (called ERISA), but their rules governing appeals are similar to those described above. They do not, however, have an independent medical review process. For more information visit their Web site at www.dol.gov and click on the Employee Benefits Security Administration (EBSA) page or call 1-866-444-3272.

http://www.healthhelp.ca.gov/

http://www.insurance.ca.gov/

http://www.healthhelp.ca.gov/

http://www.dol.gov/


EARLY START OF ORANGE COUNTY CONSENT FOR EVALUATION

Web Form RCOC #510 ES – Rev. 5/20 Early Start Consent for Evaluation

Your written consent is needed before an evaluation can begin. The evaluation will help the family and agency learn about your child. This is also a time that you begin finding out what services are available and which persons/agencies provide them. Learning about each other usually takes a little time and may involve talking with you about your child's development, observations of your child in the home or other settings and a review of medical and other records. This information will assist us in determining your child's needs and eligibility for a program.

Agency to evaluate: Regional Center of Orange County P.O. Box 22010 Santa Ana, CA 92702-2010

714-796-5100

Date of Birth: Name of Child:

Child's Social Security # ______________________

For Your Information: Your consent to be involved in evaluation is entirely voluntary and may be withdrawn at any time.Evaluation is the way eligibility for services is decided: without an evaluation, services may not be provided.The evaluation will be completed in the primary language of your child and family.The evaluation will occur in a timely manner.The evaluation will help you to identify your concerns for your child and family.You may request information on the assessment tools to be used as well as a copy of the evaluation results.Information about your child and family is strictly confidential and will only be released to those

agencies/persons that you choose in writing.No services shall be started, changed, or ended without written notification to the family and the written consent

of the family.You have the right to review and inspect your child's records.You have a right to receive further written information about your rights.The evaluation will give information about your child's development.

Your child will receive assessments in the following areas: ●Developmental screening ●Vision and Hearing Screening ●Communication Development● Social Emotional Development ●Physical Development ●Adaptive Development ●Cognitive Development

PLEASE INITIAL THE STATEMENT THAT YOU AGREE WITH: I agree to evaluation to help determine if my child is eligible or continues to be eligible for early

intervention services. I understand that my consent is voluntary and that I may refuse evaluation services at any time.

I do not want my child to receive an evaluation and I understand that my child may not be able to receive early intervention services until eligibility is determined through an evaluation.

Parent/guardian signature _____________________________________ Date ______________ Translator signature __________________________________________ Date ______________


EARLY START ORANGE COUNTY

CONSENT FOR EXCHANGE OF INFORMATION

Web Form RCOC #511 ES – Rev. 8/15 Early Start Orange County Consent for Exchange of Information

With your written consent, community agencies/professionals and the persons they represent may share information with one another. This exchange of information helps to plan with you and to keep communication about your needs clear.

Requesting Agency: Regional Center of Orange County P.O. Box 22010 Santa Ana, CA 92702-2010 714-796-5100

Name of Child: Mother's Maiden Name: Date of Birth: Child’s Social Security Number: UCI #:

For your information: This Consent for Exchange of Information is good for one year unless you withdraw your consent before that

time. A photocopy of this will be considered the same as an original and an approval for release of information. Information about your child and family is strictly confidential and will only be released to those agencies/persons

whom you choose in writing. Records are kept on site in a secure location accessible only to staff. Once casesare closed, they are stored in a secure, locked area on site.

Please place your initials next to the agencies/professionals which may exchange information.

INITIAL THE RECORDS YOU AGREE CAN BE EXCHANGED _____California Children Services: ALL/MTU/FINANCIAL/OTHER ____________________________________________________________ _____Regional Center of Orange County: ALL/SOCIAL/DEVELOPMENTAL/PSYCHOLOGICAL/MEDICAL/OTHER ___________ _____Local School District: (please identify)____________________________________________________________

ALL /PHYSICAL/COGNITIVE/LANGUAGE & SPEECH/PSYCHOSOCIAL/SELF-HELP/OTHER ___________________________________ _____Orange County Mental Health: ALL/PSYCHOLOGICAL/SOCIAL/MEDICAL/OTHER ________________________________________ _____Orange County Public Health: ALL/PHN/CHDP/OTHER ________________________________________________________________ _____Orange County Social Services: ALL/MEDICAL/PSYCHOLOGICAL/SOCIAL/OTHER ______________________________________ _____Physician/s________________________________________________________________________ _____ Specialist/s (OT/PT/Speech/Other)____________________________________________________________ _____Birth Hospital ___________________________________________________________________________ _____Hospital/s_______________________________________________________________________________ _____Interagency Review Team: ALL/ PHYSICAL/COGNITIVE/LANGUAGE&SPEECH/PSYCHOSOCIAL/SELF-HELP/OTHER __________ _____Early Intervention Program/s: ALL /PHYSICAL/COGNITIVE/LANG&SPEECH/PSYCHOSOCIAL/SELF-HELP/OTHER ____________ _______ Comfort Connection FRC: ALL/PHYSICAL /COGNITIVE/LANGUAGE&SPEECH/PSYCHOSOCIAL/SELF-HELP/OTHER ___________ _______ Insurance, CalOptima: _________________________________________________________________ _____Help Me Grow of OC: ALL/ PHYSICAL /COGNITIVE/LANGUAGE& SPEECH/PSYCHOSOCIAL/SELF-HELP/OTHER ______________ _____Other persons or agencies: ALL/ PHYSICAL /COGNITIVE/LANGUAGE& SPEECH/PSYCHOSOCIAL/SELF-HELP/OTHER _________

_____ I agree to exchange information about my child among the agencies initialed above and the persons who represent them. _____ I understand that I may limit what information is exchanged and this may affect my child's services. Please list any limitations. _______________________________________________________________________ _____________________________________________________________________________________________ Parent/guardian signature _________________________________________ Date _______________

Translator signature ______________________________________________ Date _______________

© 2009 Department of Developmental Services www.dds.ca.gov/earlystart

❦ Parents’ Rights: An Early Start Guide for Families ❦Confidentiality & Access to Records

Early Start records are an important source of information about your child. The information you provide to the regional center or local education agency (LEA) about your

child and your family is confidential. Such information will only be shared with authorized persons involved in your child’s services.

As a parent,* you have the right to

1. access records, including the right to have you or your representative examine and obtain copies of records relating to your child; You may request that any regional center or LEA amend or remove information relating to your child from the records. [CFR 303.402, CCR 52164, CCR 52168]

2. receive, within five days of your request, copies of records relating to your child and/or explanations that you request; [CCR 52164]

3. request a meeting with the director of the regional center or the superintendent of the LEA about information contained in the record; and [CCR 52168]

4. have personally identifiable information about your child maintained in a confidential manner and have its sources, access, uses, and policies for location, storage, disclosure, retention, and destruction explained to you per the Family Education Rights and Privacy Act. [CFR 303.401, CFR 303.460, CCR 52160, CCR 52162, CCR 52165, CCR 52169]

Evaluation & Assessment

The determination of eligibility for Early Start in California includes a timely, comprehensive, multidisciplinary evaluation and assessment of every child under age

three years who is suspected to be in need of early intervention services. If no parent or guard-ian is available or the child is a ward of the court, a knowledgeable surrogate parent who has no conflicting interest will be appointed. Procedural safeguards ensure that families are provided their rights under the law. [CFR 303.322, CFR 303.406, CCR 52082]

As a parent, you have the right to

1. be fully informed of your rights under Early Start; [CFR 303.403, GC 95020(c), CCR 52160, CCR 52161]

2. refer your child for evaluation and assessment, provide information throughout the pro-cess, make decisions, and give informed consent for your child’s early intervention services; [CFR 303.401, CFR 303.404, CCR 52040(d)]

3. understand and provide voluntary written permission or refusal before the initial evalua-tion and assessments are administered; [CFR 303.405, CCR 52162]

4. participate in the initial evaluation and assessment process including eligibility determina-tion; [CFR 303.322, GC 95020, CCR 52082, CCR 52084]

5. receive a completed initial evaluation and assessment within 45 days after the referral of your child to a regional center or an LEA; [CFR 303.321, CFR 303.322, CCR 52086]

6. participate in a meeting to share the results of evaluations and assessments; and[GC 95020(b)]

7. participate in all decisions regarding eligibility and services. [CFR 303.343, GC 95014(a), GC 95020(b), CCR 52082(a), CCR 52104]

The Individuals with Disabilities Education Act (IDEA) requires the following:

1. Evaluation and assessment materials are administered in the language of the parents’ choice or other mode of communication, unless it is clearly not feasible to do so. [CFR 303.323, CCR 52084]

2. Evaluation and assessment procedures and materials are selected and administered so as not to be racially or culturally discriminatory. [CFR 303.323, CCR 52082]

3. Evaluation and assessment materials are appropriate to assess the specific areas of devel-opmental need and are used for the specific purposes for which they were designed. [CFR 303.322, CCR 52082]

4. Evaluations and assessments are conducted by qualified personnel. [CFR 303.322, CCR 52082, CCR 52084]

5. Evaluations and assessments administered to children with known vision, hearing, orthopedic, or communication impairments are selected to accurately reflect the child’s developmental level. [CFR 303.322, CCR 52082]

6. Evaluations and assessments are administered in the five developmental areas, which include physical development (motor abilities, vision, hearing, and health status); com-munication development; cognitive development; adaptive development; and social or emotional development. Assessments and evaluations are ongoing while your child is in Early Start. [CFR 303.322, CCR 52082, CCR 52084, CCR 52102]

7. Evaluations and assessments shall be conducted in natural environments whenever pos-sible. [CCR 52082(i), CCR 52084(e)]

8. Pertinent records relating to your child’s health status and medical history are reviewed. [CFR 303.322, CCR 52082]

9. No single procedure is used as the sole criterion for determining your child’s eligibility for early intervention services. [CFR 303.323, CCR 52082]

10. Interviews to identify family resources, priorities, and concerns regarding the development of your child and your family’s needs are voluntary. [CFR 303.322, CCR 52084, CCR 52106]

Individualized Family Service Plan

An individualized family service plan (IFSP) is a written plan for providing early intervention services to an eligible child and the child’s family. For an infant or toddler

who has been evaluated for the first time, a meeting must take place within 45 days of the refer-ral to the regional center or LEA to share the results of the evaluation, to determine eligibility, and, for children who are eligible, to develop the initial IFSP. Evaluation results and determina-tion of eligibility may be shared with families prior to the first IFSP meeting. [CFR 303.340, CFR 303.342, GC 95020(b), CCR 52100, CCR 52102]

A periodic review of your child’s IFSP must take place at least every six months. A review may occur more frequently if there are any changes to the IFSP or if you request a periodic review with the regional center or LEA. The IFSP must also be reviewed annually to evaluate how your child is doing and to make any needed changes to the IFSP. [CFR 303.342, CCR 52102]

During the development and implementation of an IFSP, you have the right as the parent to1. attend the IFSP meetings and participate in developing the IFSP; [CFR 303.343, CCR 52104]

2. invite other family members to attend IFSP meetings; [CFR 303.343, CCR 52104]

3. invite an advocate or persons other than family members to attend and participate in the IFSP meetings; [CFR 303.343, CCR 52104]

4. have a copy of the complete IFSP; [CFR 303.402, CCR 52102]

5. have the contents of the IFSP fully explained in the language of your choice; [CFR 303.342, CFR 303.403, CCR 52102]

6. give consent to services listed on the IFSP. If you do not give consent to a service, it will not be provided. You may withdraw consent after initially accepting or receiving a service; [CFR 303.342, CFR 303.404, CFR 303.405, CCR 52102]

7. have services provided in the natural environment or an explanation of why that is not possible; [CFR 303.12, CFR 303.344, CCR 52106]

8. exchange information about your child among other agencies; [CFR 303.460, CCR 52112, CCR 52169]

9. be notified in writing before any agency or service provider proposes or refuses to initiate or change your child’s identification, evaluation, assessment, placement, or the provision of appropriate early intervention services to your child or your family. [CFR 303.403, CCR 52161]

The notice must contain: • the action that is proposed or refused, • reasons for the action, and • all available procedural safeguards.

The notice must be presented in the language of your choice, unless it is clearly not feasible to do so, and may be translated so that you understand its contents.[CFR 303.400 to 303.460, CCR 52161]

* Refer to CCR 52000(b)(36) for definition of parent.

© 2009 Department of Developmental Services www.dds.ca.gov/earlystart

Mediation Conferences, Due Process Hearings, and State Complaints

PA R E N T S ’ R I G H T S : A N E A R LY S T A R T G U I D E F O R F A M I L I E S

In Early Start, parents have rights and protections to assure that early intervention services are provided to their children in a manner appropriate to their needs, in consid-

eration of family concerns, and in compliance with applicable federal and State statutes and regulations. The following procedures are only for children under the age of three years. [CFR 303.422, CCR 52170, CCR 52172, CCR 52173, CCR 52174]

As a parent, you have the right to1. request a mediation conference and/or a due process hearing any time a regional center

or LEA proposes or refuses to initiate or change the identification, evaluation, assessment, placement, and/or provision of appropriate early intervention service(s); [CFR 303.419, CFR 303.420, CCR 52172]

2. be informed of your right to file a complaint or a request for mediation or due process; [CFR 303.510, CCR 52170]

3. file a complaint if you believe there has been a violation of any federal or state statute or regulation governing early intervention services under Early Start including eligibility and services; and [CFR 303.511, CCR 52170]

4. request a mediation conference immediately, prior to a complaint or due process hearing request, or at any time during the complaint/due process hearing processes to resolve a dispute related to any matter concerning federal or state statute or regulation governing early intervention services under Early Start [CCR 52170(b)]; and

5. file a complaint if a due process decision fails to be implemented. [CCR 52170(b)]

MEDIATION CONFERENCESMediation is a flexible, non-binding, confidential process in which a neutral mediator facilitates settlement negotiations between you and another party. Voluntary impartial mediation confer-ences are a more informal way to resolve disagreements with early intervention service agencies or to address alleged violations of any state and federal statutes or regulations. Mediation is voluntary [CFR 303.419, CCR 52173].

As a parent you have the right to1. file a request for mediation as the initial option for resolving a dispute or any time during the

due process hearing or complaint process [CFR 303.419, CCR 52173];2. request a due process hearing or file a state complaint if the disagreement is not resolved

[CCR 52173];3. refuse to participate in mediation [CFR 303.419, CCR 52173];4. have an impartial person facilitate the mediation conference [CFR 303.419, CCR 52173(c)];5. require that the mediation conference is carried out at a time and in a location that is reason-

ably convenient for you [CFR 303.419, CCR 52173];6. have all personally identifiable information maintained in a confidential manner [CFR

303.419(b), CCR 52173(g)]; and 7. receive a written document outlining the agreements reached as a result of the mediation

conference [CFR 303.419, CCR 52173(i)].

Requests for mediation are filed with the: Office of Administrative Hearings Attention: Early Start Intervention Section 2349 Gateway Oaks Drive, Suite 2000, Sacramento, CA 95833 (916) 263-0654 Fax: (916) 376-6318 [CCR 52173]

DUE PROCESS HEARINGS All parents are encouraged to resolve differences at the lowest administrative level possible. When differences between you and a regional center or LEA cannot be resolved, due process hearings are available. You, as a parent, are encouraged to seek assistance from your child’s service coordinator, the regional center, or the Special Education Local Plan Area (SELPA) office. [CFR 303.420, CCR 52172]

Circumstances leading to a due process hearing may be disagreements related to a proposal or refusal for identification, evaluation, assessment, placement, or services. [CCR 52172(a)]

Your child will continue to receive the early intervention services identified on the IFSP that he/she is currently receiving unless you and the regional center or LEA otherwise agree to a change. If your disagreement involves a new service that has not started, your child will receive all services identified on the IFSP that are not in dispute. This does not include your regional center providing early intervention services after your child has reached 36 months of age, as federal law and regulations do not allow states to pay for early intervention services under any circumstances once your child transitions from Early Start. The program or programs your child enrolls in subsequent to transition from Early Start is responsible for providing you and your child services for which he or she is eligible to receive. [CCR 52172(g)]

Requests for a due process hearing are filed with the Office of Administrative Hearings at the following address:* [CFR 303.420, CCR 52172] Office of Administrative Hearings Attention: Early Start Intervention Section 2349 Gateway Oaks Drive, Suite 200, Sacramento, CA 95833 (916) 263-0654 Fax: (916) 376-6318 [CCR 52172] *The due process hearing request form may be obtained from your service coordinator, the regional center, the LEA, and DDS website: www.dds.ca.gov/Forms/pdf/DS1802.pdf

The due process hearing must be completed within 30 days of receipt of the request by the Of-fice of Administrative Hearings. The timely issuance of the written decision may not be delayed by any concurrent voluntary local efforts to resolve the matter. The decision will be final unless appealed. [CFR 303.425, CCR 52172(e)]

STATE COMPLAINTSAny individual or organization may file a signed, written complaint against the Department of Developmental Services (DDS), the California Department of Education (CDE), or any regional center, LEA, or private service provider that receives Part C funds alleging violations of State or federal early intervention statute or regulation. The complaint process can also address rem-edies for denial of eligibility or appropriate services. However, even though DDS is mandated to investigate any complaint it receives, state law does not allow disclosure of the Early Start recipient’s personally identifiable information without written parental consent, other than authorized employees specified by the regional center or LEA [CFR 303.510, CCR 52170(a)].

Information or assistance in filing complaints is available from your child’s service coordinator, the regional center office, or the special education local plan area (SELPA). DDS and CDE are available for consultation regarding the filing of a complaint. Additional assistance is available from advocacy organizations such as the State Council on Developmental Disabilities or Dis-abilities Rights California. As efforts to resolve the matter at the local level are undertaken, a complaint may be filed concurrently with a request for a mediation conference or due process hearing. [CFR 303.423, CCR 52170]

Complaints are filed directly with the

Department of Developmental Services Office of Human Rights and Advocacy Services Attention: Early Start Complaint Unit 1600 9th Street, Room 240, MS 2-15 Sacramento, CA 95814 (916) 654-1888 Fax (916) 651-8210 [CCR 52170(e)]

Any individual or organization who files a complaint has the right to[CCR 52170]

1. receive assistance in filing the complaint from the service coordinator, regional center, or LEA; [CCR 52170]

2. not be compelled to use any other procedures under the Education Code or the Lanterman Developmental Disabilities Services Act to resolve the complaint; [GC 95007, CCR 52170]

3. submit additional information to DDS that may be helpful to the investigation; [CCR 52170]

4. receive a final written decision within 60 days of the date DDS receives the complaint; [CCR 52170]

5. receive appropriate remedies that may include monetary reimbursement or other corrective action, and assurance that services will be provided appropriately in the future if the deci-sion of DDS includes remedies for denial of appropriate services; [CCR 52170]

6. have any issue in a complaint that is not part of a due process hearing be resolved by DDS within 60 days of the receipt of the complaint; [CFR 303.512(c), CCR 52171(c)]

7. be notified by DDS that the hearing decision is binding if an issue is being raised in a com-plaint that had previously been decided in a due process hearing involving the same parties; and [CCR 52170]

8. have any complaint resolved that alleges the failure of a public agency or private service provider to implement a due process decision. [CCR 52170]

The complaint must1. be in writing and contain a signed statement alleging that DDS, CDE, the regional center,

LEA, or other service provider involved with Early Start has violated a federal or State law or regulation; [CCR 52170(a)]

2. provide the name, address, and phone number of the complainant; [CCR 52170(f)]

3. contain a statement of facts upon which the violation is based; [CCR 52170(f)]

4. include the name of the party responsible against whom the complaint is being filed; [CCR 52170(f)]

5. have occured not more than one year before the date the complaint is received by DDS unless a longer period is reasonable because the alleged violation continues for the child or other children, or [CCR 52170(c)]

6. have occured not more than three years before the date on which the complaint is received by DDS if the complainant is requesting reimbursement or corrective action as remediation of the complaint [CCR 52170(c)]; and

7. the complaint may also include, if applicable, a description of the voluntary steps taken at the local level to resolve the complaint. [CCR 52170]

8. be withdrawn if the complainant elects to participate in mediation within the 60-day complaint investigation.

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