CHILD AND FAMILY CONNECTIONS PRE-BILLING INSURANCE WAIVER REQUEST Child’s Last Name, First Name & Middle Initial Child’s Date of Birth (Month/Day/Year) Current IFSP Begin Date EI # Current IFSP End Date CFC # This form serves as certification of the existence of criteria defined in Illinois State Law and/or Administrative Rule to waive the requirement of private insurance use for Early Intervention (EI) services. A decision will be made within ten (10) business days of your request. This Waiver will only apply to the service and/or plan or policy for which the outlined criterion exists. Check type of pre-billing waiver requested 1) Insurance provider NOT available to receive the referral and services immediately (i.e., within 15 business days). 2) Insurance provider NOT enrolled and credentialed as a provider in the EI Program. 3) Family would have to travel more than an additional 15 miles or an additional 30 minutes to the insurance provider as compared to travel to a different enrolled and credentialed provider. Payee’s Name Date Tax ID of Payee Provider’s Discipline Type Service Coordinator’s Name Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, the Family Educational Rights and Privacy Act, 20 USC 1232g, and the Health Insurance Portability and Accountability Act of 1996, information collected hereunder may not be redisclosed unless the person who consented to this disclosure specifically consents to such redisclosure or the redisclosure is allowed by law. **CFC must submit form and documentation electronically through secure Webmail to Central Billing Office (CBO) for review** PRE-BILLING INSURANCE WAIVER REQUEST APPROVAL/DENIAL For CBO Use Only: Waiver Approval Date: Effective Dates: To Waiver Denial Date: CBO Staff Initials: Reason for Denial:
CHILD AND FAMILY CONNECTIONS PRE-BILLING INSURANCE WAIVER REQUEST Child’s Last Name, First Name & Middle Initial Child’s Date of Birth (Month/Day/Year) Current IFSP Begin Date EI # Current IFSP End Date CFC # This form serves as certification of the existence of criteria defined in Illinois State Law and/or Administrative Rule to waive the requirement of private insurance use for Early Intervention (EI) services. A decision will be made within ten (10) business days of your request. This Waiver will only apply to the service and/or plan or policy for which the outlined criterion exists. Check type of pre-billing waiver requested 1) Insurance provider NOT available to receive the referral and services immediately (i.e., within 15 business days). 2) Insurance provider NOT enrolled and credentialed as a provider in the EI Program. 3) Family would have to travel more than an additional 15 miles or an additional 30 minutes to the insurance provider as compared to travel to a different enrolled and credentialed provider. Payee’s Name Date Tax ID of Payee Provider’s Discipline Type Service Coordinator’s Name Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, the Family Educational Rights and Privacy Act, 20 USC 1232g, and the Health Insurance Portability and Accountability Act of 1996, information collected hereunder may not be redisclosed unless the person who consented to this disclosure specifically consents to such redisclosure or the redisclosure is allowed by law. **CFC must submit form and documentation electronically through secure Webmail to Central Billing Office (CBO) for review** PRE-BILLING INSURANCE WAIVER REQUEST APPROVAL/DENIAL For CBO Use Only: Waiver Approval Date: Effective Dates: To Waiver Denial Date: CBO Staff Initials: Reason for Denial: