This referral form is intended to be used for children ages birth to 3 who are enrolled in the Arizona Early Intervention Program (AzEIP).
If the child is not enrolled in AzEIP, please use AzEIP's online form, located at this online address:
https://azeip.azdes.gov/AzEIP/AzeipRef/Forms/Categories.aspx
As required per AAC R9-13-207 E)(11)(d), referral information will automatically be shared with the following: the Arizona Early Intervention Program (AzEIP) and Department of Health Services Office of Newborn Hearing Screening (Hearing Referrals Only)
ASDB Fax: 928-447-5494