Early Intervention Program - Notice of Parent Declination to Provide Insurance Information

<Name of Municipality>

Notice of Parent Declination to Provide Insurance Information to the Early Intervention Program for Subrogation Purposes

I, <Name of Early Intervention Official/Designee>, am notifying the Department of Health that <Name of Parent>, who can be reached at

___________________________________________________

___________________________________________________

___________________________________________________
<telephone number, address>

has declined to provide health insurance information to the Early Intervention Program and has not provided documentation that the insurance policy under which their child, <Name of Child>, is covered is not governed under New York State laws and regulations.

The parent declined for the following reason(s):

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Name and affiliation of initial service coordinator (when applicable):

___________________________________________________

___________________________________________________

___________________________________________________
<telephone number, address>

Name and affiliation of ongoing service coordinator (when applicable):

___________________________________________________

___________________________________________________

___________________________________________________
<telephone number, address>

I / we certify that the following actions were taken in an effort to obtain insurance information from the parent:

• The initial service coordinator requested the information of the parent.
  Yes No
• The initial service coordinator reviewed the protections in Public Health Law and Insurance Law that assure use of insurance is at no cost to the parent.
  Yes No
• The parent was asked and could not or did not provide documentation from their insurer that insurance coverage applicable to their child is not governed under New York State laws and regulations.
  Yes No
• The parent has been informed and understands that this notice has been sent to the New York State Department of Health, Early Intervention Program.
  Yes No

_____________________________________________	___________________________
Initial/Ongoing Service Coordinator	Date
_____________________________________________	___________________________
EIO/D Signature	Date