Division of Specialized Care for Children

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Administrative Rules

Application Form for Families (Solicitud de Asistencia)

Application Forms for Providers:

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Hearing Screening Brochures:

Newborn Hearing Screening Program Diagnostic Evaluation Form (form 3.45)

English:
Newborn Hearing Screening: Information for Parents (form 43.00)

Newborn Hearing Screening: Instructions for Parents (form 43.01)

Español:
Exámenes Preliminares De Audición para Recién Nacidos en Illinois: Información para los Padres (form 43.00S)

Prueba de Audición Universal para Recién Nacidos en Illinois:Instrucciones Importantes para los Padres (form 43.01S)

Polski:
Program skriningu sluchu noworodków w stanie Illinois: Informacje dla rodziców (43.00P)

Program skriningu sluchu noworodków w stanie Illinois: Wazne instrukcje dla rodziców (43.01P)

The Home Care Program

Home Care Program brochure (Medicaid Home & Community Based Services Waiver for Medically Fragile, Technology Dependent Children)
- English
- Spanish

Home Care Provider Forms:

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Illinois Provider Directory for Children with Special Health Care Needs & their Families

Illinois Provider Directory Application form

Information Library for Families

Institute for Parents of Preschool Children Who are Deaf or Hard of Hearing:

Insurance: Questions & Answers About Health Insurance brochure

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K

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Links to Resources & Information

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Medical Home:

Creating a Medical Home: The Foundation for Primary Care Delivery

Parent Partnerships

Practice Assessment

Consumer Awareness

Practice Improvements

Preventive Care Management

Acute Illness Management

Chronic Condition Management

Diagnosis Modules

Transition Information

Community Resources

Medical Home Reimbursement

Quality Improvement

Medical Home CME Monograph for Physicians

Medical Home Brochure for Families

Medical Home Brochure for Providers

Medical Home Services: DSCC Reimbursement Guidelines

Medical Home: What Families Need to Know

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Newborn Hearing Screening Brochures:

Newborn Hearing Screening Program Diagnostic Evaluation Form (form 3.45)

English:
Newborn Hearing Screening: Information for Parents (form 43.00)

Newborn Hearing Screening: Instructions for Parents (form 43.01)

Español:
Exámenes Preliminares De Audición para Recién Nacidos en Illinois: Información para los Padres (form 43.00S)

Prueba de Audición Universal para Recién Nacidos en Illinois:Instrucciones Importantes para los Padres (form 43.01S)

Polski:
Program skriningu sluchu noworodków w stanie Illinois: Informacje dla rodziców (43.00P)

Program skriningu sluchu noworodków w stanie Illinois: Wazne instrukcje dla rodziców (43.01P)

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Office Lookup

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Privacy Practices Notice (Aviso Sobre Prácticas de Privacidad )

Programs:

The Children's Habilitation Clinic

The Core Program

The Home Care Program

Provider Information & Resources:

Illinois Provider Directory for Children with Special Health Care Needs & their Families

Illinois Provider Directory Application form

DSCC Provider Approval Criteria

DSCC Reimbursement Procedure

DSCC Provider Application Forms:

Training and Experience Form

TIN & Legal Status Certification Form

Complete and submit only one (1) of the following:

Liability Insurance Statement
(for Physicians and Health Care Professionals)

Liability Insurance Statement
(for Health Care Facilities)

Liability Insurance Statement
(for Therapy Groups)

Liability Insurance Statement
(for Contractors)

Liability Insurance Statement
(for Home Care Agencies)

Liability Insurance Statement
(for Other Health Care Providers)

Newborn Hearing Screening Brochures:

Newborn Hearing Screening Program Diagnostic Evaluation Form (form 3.45)

English:
Newborn Hearing Screening: Information for Parents (form 43.00)

Newborn Hearing Screening: Instructions for Parents (form 43.01)

Español:
Exámenes Preliminares De Audición para Recién Nacidos en Illinois: Información para los Padres (form 43.00S)

Prueba de Audición Universal para Recién Nacidos en Illinois:Instrucciones Importantes para los Padres (form 43.01S)

Polski:
Program skriningu sluchu noworodków w stanie Illinois: Informacje dla rodziców (43.00P)

Program skriningu sluchu noworodków w stanie Illinois: Wazne instrukcje dla rodziców (43.01P)

Core Program Treatment Forms:

IDPH Newborn Screening Program Diagnostic Evaluation Form (form 3.44)

Therapy Treatment Plan (form 05.27)

Pediatric Ophthalmologic Report (form 05.26)

Physician Recommendation for Hearing Aids (form 05.32)

Evaluation/Training for Use of Equipment (Vendor Form) (form 05.33-2)

Evaluation/Training for Use of Equipment (Therapist Form) (form 05.33-3)

Home Care Provider Forms:

Price Estimate for Medical Equipment & Supplies (PDF)

Home Care Billing Form (PDF)

Home Care Billing Form (Word)

Transition Tools for Providers:

Transition Information Sheet

Transition Checklist and Timeline

Teen Transition Facts for Health Professionals

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Resource Links

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School to Work Checklist (De la escuela al trabajo lista de comprobación)

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Text-only version of our site

Title V: What is it?

Transition:

Transition Timeline

Transition Information Sheet for Families (Información sobre la Transición)

Transition Information & Resources

Transition Milestones Skills Lists For Parents, Caregivers and Others

Transition Milestones Skills Lists Just for Teens

Transition: Bridging the Gap Between Pediatric and Adult Services

Family Handbook on Future Planning

Preparing for the Future: Transition to Adulthood

Work & You: Your Special Health Care Needs in the Workplace