Minnesota Dept. of Human Services

EIDBI referral form (DHS-6751S)
 DHS will use the information you enter on this form to help locate a CMDE provider. Allow up to one week for a response. DHS will contact you with a list of potential CMDE providers and talk about next steps. You will then need to contact the provider to schedule an appointment.
 If you are making a referral for a parent or caregiver, you must obtain consent and a release of information (ROI) signed by the child’s parent/ guardian before making a referral. There is a place at the end of this form to attach the completed/signed ROI form.
 If you have questions or need to request an accommodation, contact the EIDBI team with the DSD Contact Form.
 If you need free help interpreting this document, call  651-431-4300 or 866-267-7655. For accessible formats of this document or assistance with additional equal access to human services, call 651-431-4300 or 866-267-7655 (toll free), write to DHS.Info@state.mn.us or use your preferred relay service.
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