Health Planning Council of Southwest Florida

EMAIL US AT CEO@HPCSWF.COM
CALL US NOW (239) 433-6700 Ft. Myers
(941) 487-5400 Sarasota
SWFL Resource Link

Provider Forms

Provider Forms

Provider Contract Updates for FY 2017-18

Provider Contract (2017-2018)

Audiology Provider Contract (20170703)  |  Early Steps Invoice Audiology (20160701)

 

Additional Forms & Resources for Providers

Early Steps Next Steps Daily Session Note Template | DSN-PDF

Early Steps Consultation Form

Early Steps Early Intervention (EI) Forms: GUIDELINES | EI Report (BLANK) 20171003 | EI Template with Prompts

 

Zone Meeting Documents: AGENDA | MINUTE | MINUTE (NOT POC)

Quality Assurance (QA): QA Video Requirement | Schedule for STAFF 2017-18 | Schedule for CONTRACTORS 2017-18

  • QA Videos are submitted annually to your team leader (Staff) or Jeremi Grosser (Contractors).
  • For assistance in submitting your video, please contact Kristin Peras or Jeremi Grosser in advance to ensure they are available to assist you on a specific day/time.

Family Guided Routines Based Intervention (FGRBI): Implementation Process | Key Indicators

Measure of Engagement, Independence, and Social Relationships (MEISR)  | Fillable Form (MEISR)  | MEISR Spanish

  • This is not a required form, but could prove very useful to get a comprehensive picture of all developmental aspects of a child.

ES Measuring Progress Toward Goals Template (20140701) | MPTG-PDF

Routines Based Outcomes Handout

  • Use this form to help build Outcomes with your Families and to make sure you are addressing your Family’s Needs as it pertains to Early Intervention.

ES Health History Questionnaire Template | HHQ-PDF | Suggested uses: HHQ

  • This is not a required form, but could prove very useful during Intake, Eval, Exit and by the family’s PSP.

ES Review of Systems

  • This is not a required form, but could prove very useful to get a comprehensive picture of all developmental aspects of a child.

Insurance Verification Form | ESPAÑOL

  • This form is used by Service Coordinators and/or Providers to collect insurance information for third party billing. The form is an Adobe pdf and can be edited on the computer, however the form must have original-ink signatures.

Insurance EOB Denial Log

  • This form is used to document attempts to contact/bill Private Insurances. You must submit with your invoice to show proof of attempts.

M-CHAT | ESPAÑOL | Scoring Instructions

  • This stands for Modified Checklist for Autism in Toddlers and is used as an Autism Screening Tool.

ES Photo & Video Release | ESPAÑOL

IFSP Team Guide

PSP Approach Brochure | ESPAÑOL

CMS Referral Form

  • This form is used by any individual to refer a child to CMS.

 

As new documents become available, they will be posted and updated on this page.