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SCDHHS/IDEA PART C/01JUL2020/ALL PREVIOUS VERSIONS ARE VOID
PARENT VERIFICATION OF EIS FORM
PARENT VERIFICATION
OF SERVICES
SECTION 1: CHILD AND EARLY INTERVENTION SERVICE (EIS) PROVIDER INFORMATION
Name of Child:
BRIDGES ID #:
Month/Year:
Name of EIS Provider:
Name of Agency/Company:
SECTION 2: EIS INFORMATION
EIS Provided
☐ PT
☐ SC
☐ SI
☐ SLP
☐ Other
NOTE TO PARENT: Your signature on this form confirms that the service was provided on the date and at the times
listed and is the basis for payment to the EIS provider by IDEA/Part C. Please DO NOT sign any blank, incomplete, or
incorrect lines.
Check one
Check one
Date of
Service
Beginning
Time
A.M.
P.M.
Ending
Time
A.M.
P.M.
Signature of Parent
Date
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☐ ☐
SECTION 3: EIS PROVIDER ACKNOWLEDGEMENTS AND SIGNATURE
By signature below, I certify that I have provided the services listed for this child. I further acknowledge that the original
signed parent verification form must be maintained on file in the event of audit by IDEA/Part C for not less than three
years after the last date of service.
Sig nature of EIS Provider
Date
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Completed 11 March 2022

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