Primary Health Care Provider IFSP Review Cover Letter
On Agency Letterhead
Date: Physician’s or APRN’s Name: Re: Dear primary health care provider: The above child has been receiving early intervention services from our program. The most recent Individual Family Service Plan (IFSP) was developed on _____________ and was previously sent to you for your signature. A revision of this child’s IFSP has been made and your agreement for the change(s) in services is needed. The recommended change(s) and reason is: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Please sign the attached “Individualized Family Service Plan (IFSP) Review: Services and Supports” and return it in the self addressed envelope provided. You may contact me at _____________________________ if you wish to discuss your patient’s services further. Please keep the enclosed copy of the IFSP Review for your records. Sincerely, D.O.B.:
Service Coordinator
cc:
child record
Connecticut Birth to Three Form 3-7 (Revised 7/1/2004)