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NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF …

Revised October 2019 NEW york STATE DEPARTMENT OF HEALTH BUREAU OF EARLY INTERVENTION INSURANCE Tool Kit for Service Coordinators Tool Kit Items: 1. Initial Service Coordinator Insurance Responsibilities 2. Ongoing Service Coordinator Insurance Responsibilities 3. Collection of Insurance information Form A 4. Child Insurance information Form B 5. Authorization to Release HEALTH Insurance information Form C 6. Request for Coverage information Form D 7. Instructions for Ongoing Service Coordinators: Collecting the Written Referral from Parents or Primary HEALTH Care Practitioners 8. Written Referral from Primary HEALTH Care Practitioner Form E 9. Parent Notice Regarding Insurance 10. ITEM 10 Form F- Has been removed- no longer applicable 11. Required Notice of Subrogation Sample 12.

2) Collect insurance policy information from family (10 NYCRR 69-4.6(d)). a. Service Coordinators should give the family Form B (Child Insurance Information) and the form instructions. Service Coordinators should review the instructions with the parents and assist them with completing Form B (Child Insurance Information). b.

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