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New York COLLECTION OF INSURANCE INFORMATION form

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Insurance
Tool Kit Item 3
Form A
NEW YORK STATE DEPARTMENT OF HEALTH
BUREAU OF EARLY INTERVENTION
COLLECTION OF INSURANCE INFORMATION
DATE INSURANCE INFORMATION
COLLECTED/UPDATED:
*Is the Insurance Plan Regulated by
New York State?
Yes No
If no, has the parent consented to
use of their insurance benefits?
Yes No
Is the Insurance Plan:
Primary or Secondary
Child’s Name:
Child’s Date of Birth:
Child’s Gender:
Parent/Guardian Name:
Parent/Guardian Date of Birth:
Parent/Guardian Phone No.:
Insurance Company Name:
Insurance Company Phone No:
**Insurance Company Billing and
Claiming Address:
Insurance Plan/Policy Name:
Type of Insurance Plan:
Policy Holder Name:
Policy Holder Date of Birth:
Policy Holder Gender:
Policy Holder Address:
Policy Holder Phone Number:
Policy Holder Relationship to Child:
Policy Holder Employer Name:
Employer Address:
Employer Phone No.:
Policy No. for Billing:
Child’s Member Identification No:
Group Number (if applicable):
Policy Effective From Date:
Policy Effective To Date:
Is the Plan Child Health Plus?
Yes No
Is the Plan Medicaid Managed Care?
Yes No
Is the Plan a self-funded plan?
Yes No
***Medicaid CIN Number
(2 alpha, 5 numeric, 1 alpha):
CIN Effective From Date:
CIN Effective To Date:
Service Coordinator Name:
Service Coordinator Phone No:
Service Coordinator Fax No.:
Municipality Name:
Service Coordinator Agency:
Service Coordinator Address:
NEW YORK STATE DEPARTMENT OF HEALTH
BUREAU OF EARLY INTERVENTION
COLLECTION OF INSURANCE INFORMATION (continued)
NYEIS Child
Reference #:
*For assistance in determining whether a particular insurance plan is regulated in New York State, please visit:
Revised 9/13
https://myportal.dfs.ny.gov/web/guest-applications/ins.-compy-search. Please also conslt the municipality in which the family resides for
additional assistance with this determinatn.
RRRr
Revised May 2017
mm/dd/yyyy
Insurance Company Billing Address:
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
Revised May 2017
NEW YORK STATE DEPARTMENT OF HEALTH
BUREAU OF EARLY INTERVENTION
COLL
ECTION OF INSURANCE INFORMATION FORM A INSTRUCTIONS
Medicaid and Private Insurance:
If the family has both private insurance and public insurance (Medicaid) coverage, claims for
payment of early intervention services will first be billed to private insurance and only the
remaining balance will be billed to public insurance (Medicaid) for payment. If the child is
enrolled in the Medicaid Program, consent has already been provided to bill any private
insurance coverage available to the child for early intervention services. The child’s insurance
plan will be billed for early intervention services and no additional consent is needed from the
family if the child’s insurance is subject to New York State Insurance Law. Parent consent will
be needed to bill the child’s insurance plan if the plan is not subject to New York State
Insurance law.
Note:
Asterisks below correspond to boxes on Form A.
*For a
ssistance in determining whether an insurance plan is regulated in New York State,
please contact the insurer directly.
**T
he insurance company must be contacted to confirm the billing and claiming address. Once
confirmed, this should be entered/verified in NYEIS.
***If the family has a Medicaid card and CIN#, the CIN# must be entered in NYEIS. If the
Medicaid coverage is a Medicaid managed care plan, the managed care insurer/insurance
information must also be entered on the commercial insurance page and marked “Yes” for
Medicaid Managed Care after entering the Medicaid coverage. Please see Item 12 in this tool
kit for more information.
Revised May 2017
NEW YORK STATE DEPARTMENT OF HEALTH
BUREAU OF EARLY INTERVENTION
AUTHORIZATION TO RELEASE HEALTH INSURANCE INFORMATION
Pursuant to Section 2559(3)(d) of NYS Public Health Law and
Section 3235-a(c) of the Insurance Law
Insured’s (Child’s) Name:
Date of Birth:
Parent/Legal Guardian’s Name:
Date of Birth:
Insurance Company Name:
Insurance Plan Name/Type:
Insurance Company Address:
Insurance Company Phone No:
Policy Holder’s Name and Address:
Policy/ID No.:
Child’s Member ID No.:
Group No. (if applicable):
Service Coordinator Name:
Service Coordinator Agency:
Service Coordinator Address:
Service Coordinator Phone No.:
Municipality:
Date Sent to Insurer:
I request and authorize the release of health insurance coverage information for the insured
named above to my child’s and family’s early intervention service coordinator, provider(s), the
municipality which administers the local Early Intervention Program, and the NYS Department of
Health and/or its early intervention fiscal agent.
I authorize the exchange of information between these parties and the insurer named above for
the purposes of facilitating claiming and assisting in the adjudication of claims for services
rendered under the Early Intervention Program:
I further consent and authorize providers who submit claims to the above referenced insurer to
provide such information as may be required by the insurer to facilitate claiming and payment
for services rendered under the Early Intervention Program.
This request applies only to health insurance coverage under the insured’s policy, plan or
benefit package for the purposes of facilitating payment from the insurer for services rendered
under the Early Intervention Program.
Parent/Guardian’s Signature: ______________________________________________
Date Signed: ___________________________________________________________
Insurance
Tool Kit Item 5
Form C
NYEIS Child
Reference #:
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
click to sign
signature
click to edit
Page 1 of 2
Revised May 2017
NEW YORK STATE DEPARTMENT OF HEALTH
BUREAU OF EARLY INTERVENTION
REQUEST FOR COVERAGE INFORMATION
Pursuant to Section 3235-a(c) of New York State Insurance Law
Child’s Name (First/MI/Last):
Child’s Date of Birth:
Municipality:
Date Sent to Insurer:
Name of Parent/Legal Guardian:
Phone No.:
Insurance Company/Plan Name:
Insurance Company Address:
Policy Holder Name and Address:
Policy Holder Relationship to Child:
Policy Holder Date of Birth:
Policy No. for Billing:
Policy Holder Employer Name:
Policy Holder Employer Address:
Child’s Member Identification No.:
Group No. (if applicable):
Early Intervention Service Coordinator:
Service Coordination Agency:
Service Coordinator Phone No.:
Service Coordinator Fax No.:
Service Coordinator Address:
Dear Insurer:
This form requests information about the above named child’s insurance coverage. The
parent/guardian of the above named child has authorized release of this information (authorization
form enclosed). As per requirements in Section 3235-a(c) of the New York State Insurance Law, we
request that you complete and return this form to the Early Intervention Program at the address
provided above. Section 3235-a(c) of the State Insurance Law requires this information to be
returned within 15 days of request. Provision of this information will assist both the authorized
providers and the insurer in claims processing.
Please provide the following requested information regarding the above named child’s
benefits as the insured.
Is the child’s health coverage:
a) A health insurance policy, plan or benefit package
regulated under New York State Law Yes No
b) Child Health Plus Yes No
c) Other government plan (e.g., Medicaid Managed Care) Yes No
d) A self-insured plan governed by ERISA or other plan not subject Yes No
to regulation under New York State Insurance Law?
Please indicate the effective dates of coverage for this policy: ____________________________
Insurance
Tool Kit Item 6
Form D
NYEIS Child
Reference
#:
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
Page 2 of 2
Revised May 2017
Child’s Name (First/MI/Last):
Child’s Date of Birth:
Visit Limit Information
If the child’s insurance policy, plan or benefit package IS a policy regulated by New York State
Insurance Law and IS NOT Medicaid, Champus, or a self-insured plan or other plan not subject to New
York State Insurance Law, please indicate the number of annual visits available for the covered
services identified below (if no coverage is available, please indicate by placing a ‘N’ in the second
column and a ‘0’ in the third column).
Service
Covered (Y/N)
Number of Annual Visits
Applied Behavior Analysis
Assistive Technology/Durable Medical Equipment
Audiology Services
Nursing Services
Diagnostic and Evaluation Services
Nutrition Services
Occupational Therapy
Physical Therapy
Psychological Services
Social Work Services
Special Instruction
Speech Language Therapy
Vision Services
Is prior authorization for covered services required? Yes No
Are there specific referral procedures that must be followed? Yes No
If yes, please describe the procedures that must be followed:
Please provide the name, telephone number, and email address of an appropriate contact
person for questions about the information on this form:
_________________________________ _________________ ________________
Name Phone E-mail
Please return completed form to the Early Intervention Service Coordinator at the address on
the first page of this form. Thank you for your assistance.
NYEIS Child
Reference
#:
mm/dd/yyyy
Revised May 2017
NEW YORK STATE DEPARTMENT OF HEALTH
BUREAU OF EARLY INTERVENTION
WRITTEN REFERRAL FROM PRIMARY HEALTH CARE PRACTITIONER
DOCUMENTATION OF MEDICAL NECESSITY FOR THIRD PARTY CLAIMING
Pursuant to Section 2559(3)(a)(ii) of New York State Public Health Law
Child’s Name (First/MI/Last):
Child’s Date of Birth:
Name of Parent/Legal Guardian:
Phone No.:
Service Coordinator:
Phone No.
Dear Primary Care Practitioner:
Pursuant to New York State Public Health Law Section 2559(3)(a)(ii), parents are required to provide the Early
Intervention Program with a written referral from a primary health care practitioner as documentation of the medical
necessity of early intervention services for their children who have been found eligible through a multidisciplinary
evaluation for the Early Intervention Program. This information is sought in order to facilitate claims and payment
processing for these services from third party insurance. The New York State, Bureau of Early Intervention developed
this form to facilitate a complete and accurate referral. However, you may use the form of your choosing provided it
contains all the required information. Thank you for your support in providing the information requested below.
Patient Assessment and Relevant Medical History
Diagnosis, including diagnosed condition or developmental delay (and accompanying ICD code), relating to the need for
Early Intervention Program services
Early Intervention Program Services identified in the child’s Individualized Family Service Plan (IFSP)
Service Type
Frequency/Duration
Prior Auth No.
(insurer use only)
Service Type
Frequency/Duration
Prior Auth No.
(insurer use only)
Per the IFSP
Per the IFSP
Per the IFSP
Per the IFSP
Per the IFSP
Per the IFSP
I understand that the Early Intervention Program services listed above may require ongoing evaluation/assessment to be
conducted on a regular basis by a qualified professional to evaluate the progress of the child.
I refer ___________________(child) to the Early Intervention Program to obtain the services identified in his/her IFSP.
Practitioner Signature: ______________________________________(original) Date: __________________________
Practitioner Name (Print): __________________________________________ Phone No.: ______________________
Practitioner Address: _______________________________________________________________________________
New York State License No.: _________________________________________ NPI No.: ________________________
Insurance
Tool Kit Item 8
Form E
NYEIS Child
Ref
erence # :
mm/dd/yyyy
Revised May 2017
NEW YORK STATE DEPARTMENT OF HEALTH
BUREAU OF EARLY INTERVENTION
CONSENT TO BILL NON-REGULATED INSURANCE
TODAY’S DATE:
*Is the Insurance Plan Regulated by New York State:
Yes No
Child’s Name:
Child’s Date of Birth:
Insurance Company Name:
Insurance Plan Name/Type:
Insurance Company Address:
Insurance Company Phone No:
Policy Holder’s Name:
Policy Holder’s Relationship to Child:
Policy Holder’s Address:
Policy/ID No.:
Child’s Member ID No.:
Group No. (if applicable):
Name of Service Coordinator:
Service Coordinator’s Phone Number:
Consent Effective From Date:
Consent Effective To Date:
Please Read
I understand that I can decide if I wish to give my permission for my health insurance plan, which
is not regulated by New York State Insurance Law, to be billed to help pay for the Early
Intervention Program services my child and family receive.
I understand that my consent is voluntary, that I can revoke my consent at any time, and that the
revocation of consent will not be retroactive.
I understand that if I give this permission, my insurance benefits may not be protected by State
Insurance or Public Health Law and that my insurer may not be prohibited from:
Applying the early intervention services to the policy's lifetime or annual monetary or visit limits.
Discontinuing or not renewing my insurance coverage because my child receives early intervention services.
Increasing my insurance premiums because my child is receiving early intervention services.
Consent to Bill Non-Regulated Insurance
I give my consent to my Early Intervention Program providers to access benefits through my
health insurance plan, which is NOT regulated by New York State Insurance Law, to help pay for
the early intervention services my child and family receive.
I do NOT give my consent to my Early Intervention Program providers to access benefits
through my health insurance plan, which is NOT regulated by New York State Insurance Law, to
help pay for the early intervention services my child and family receive.
Parent Name Parent Signature Date
Insurance
Tool Kit Item 10
Form F
NYEIS Child
Reference #:
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
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Completed 22 February 2020

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