NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF EARLY INTERVENTION INSURANCE Tool Kit for Service Coordinators Tool Kit 1. Initial Service Coordinator Insurance Responsibilities 2. Ongoing Service Coordinator Insurance Responsibilities 3. Collection of Insurance Information Form A** – 4. Notice of Parent Declination to Provide 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 Letter Regarding Regulated Insurance 10. Parent Letter Regarding Non-regulated Insurance 11. Consent to Bill Non-regulated Insurance Form F** – 12. Required Notice of Subrogation Sample** – 13. Guidance on Billing Medicaid for Children enrolled in Medicaid Managed Care Plans 14. Guidance on Entering Non-Regulated Insurance in NYEIS 15. List of New York State Regulated Insurers 16. List of Non-Regulated Insurance Plans
NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF EARLY INTERVENTION INSURANCE Tool Kit for Service Coordinators Tool Kit 1. Initial Service Coordinator Insurance Responsibilities 2. Ongoing Service Coordinator Insurance Responsibilities 3. Collection of Insurance Information – Form A** 4. Notice of Parent Declination to Provide 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 Letter Regarding Regulated Insurance 10. Parent Letter Regarding Non-regulated Insurance 11. Consent to Bill Non-regulated Insurance – Form F** 12. Required Notice of Subrogation – Sample** 13. Guidance on Billing Medicaid for Children enrolled in Medicaid Managed Care Plans 14. Guidance on Entering Non-Regulated Insurance in NYEIS 15. List of New York State Regulated Insurers 16. List of Non-Regulated Insurance Plans
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