Referral and Release Forms

These forms are designed to facilitate communication between professionals caring for children with developmental delays and special health care needs. Both forms are approved by Wisconsin Department of Health Services and allow physicians to refer to programs supporting children and youth with special health care needs.

From Physicians to:

  • Birth to 3 Program (Early Intervention)
    This voluntary Referral to Wisconsin Birth to 3 Program form was created for use by primary care clinicians to refer a child to a county Birth to 3 Program. This HIPAA- and FERPA-compliant form also serves as a joint release of information between these two sectors given parent consent. 

    There are Birth to 3 Programs in each of the 72 Wisconsin counties. Click here to locate contact information for the Birth to 3 Program in your county.
     

  • Regional Centers for CYSHCN
    Physicians may refer a child with special health care needs to one of the five Regional Centers using this referral form.

    The Consent to Release Medical Information Referral to a Regional Center for Children and Youth with Special Health Care Needs form is approved by Wisconsin Department of Health Services and posted on their website for use. The two-page voluntary release is HIPAA compliant. Parent signature on this form allows medical providers and Regional Center professionals to communicate directly with one another and expedites care for families in need of information and referral services. Providers may choose to indicate the reason for referral, including respite care, special foods or formula, and health benefits counseling. Page 2 of the form provides the information on how to determine the appropriate Regional Center to provide assistance to the family, as well as that center’s contact information.

    Are you using the physician referral form to Regional Centers? If so, we’d like to hear from you. Please let us know what’s working well with the form, along with areas that need improving. Send your feedback to: WisMHI@chw.org.

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