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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.
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| | If you have questions or need to request an accommodation, contact the EIDBI team with the DSD Contact Form. |
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