Important Forms, Reports, and More
Direct and Contracted Staff
- Contract Attachment 1: Provider Checklist
- Contract Attachment 2: Worker’s Compensation Exemption Form
- Contract Attachment 3: W-9 Form
- Contract Attachment 4: IRS I-9 Form
- Contract Attachment 5: Vendor / Subrecipient Form
- Contract Attachment 6: Training Record
This form is used by Providers to track their annual Early Intervention Trainings (12 Hours per Fiscal Year). - Contract Attachment 7: Provider Referral Checklist
This form is to be submitted with the Providers Monthly Invoice for each child documenting the Inital Date of Contact & Date Services Began for each new referral / authorization. - Contract Attachment 8: Monthly Report
This form is used by Providers to report child and family progress to the team. It is sent to Early Steps with the Monthly Invoice. - Contract Attachment 9: Summary of Family Rights
ESPAÑOL
CREOLE - Contract Attachment 10: Consultation Among Service Providers
This form is used to document consultations between team members and a copy is submitted to Early Steps with the Monthly Invoice. - Contract Attachment 11: Team Review Form
This form is used to document the individuals involved in a child’s Team Review and should be completed by each Provider involved. - Contract Attachment 12: Provider Invoice
This form is used by Providers to submit the Monthly Billing to Early Steps for their Services. - Contract Attachment 13: QA Report Form
This form is used by the Administrative Staff to review Provider Files. - Contract Attachment 14: Natural Environment Travel Log
This form is for our Providers and is used to document their travel for Early Steps appointments. - Contract Attachment 15: IAR
This form is used by Providers and Service Coordinators to document services completed.
E.I. Session Report
This form is used by Providers to document progress and updates for their individual sessions.
CMS Referral Form
This form is used by any individual to refer a child to CMS.
DBS Referral & Application for Service
Fax this completed form to the Division of Blind Services at (239)278-7351.
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.
M-CHAT | ESPAÑOL | Scoring Instructions
This stands for Modified Checklist for Autism in Toddlers and is used as an Autism Screening Tool.
Staff Travel Form
ES STAFF ONLY
As new documents become available, they will be posted and updated on this page.