Health Home Case Management/Early Intervention Service Coordination Agency Application Instructions

• Instructions also available in Portable Document Format (PDF)

To apply for New York State Department of Health, Bureau of Early Intervention approval as an early intervention agency to solely provide care management services (ongoing service coordination) for Health Homes you must complete both the Application for the Approval of Agencies and Early Intervention Provider Agreement (note - your agency will need to request the Appendix 1 Provider Agreement even though you will not be billing for services provided). Appendix 1 will allow your agency to access the child's integrated case record.
CAUTION – follow these instructions on what sections of the Application need to be completed.
Since you will be applying for Department approval solely to provide care management services, you are only required to complete certain sections of the Agency Application. Please ignore pages I through VI.

1. Begin completing the Application at page 1. Complete the following sections only:
   • ☐ Page 1, Schedule 1 – Background Information: A. Applicant Information
   • ☐ Page 2, Schedule 1 – Background Information: B. Designated EI Program Director
   • ☐ Page 3, Schedule 2 – Corporate Structure/Disclosure Requirements: A. Type of Ownership. C. Parent Organization Information – question #1 only
   • ☐ Page 9, Schedule 4 – Applicant Agency Affiliation: A. Health, Education, Developmental Disabilities, and Mental Hygiene Agencies – question #1 only.
   • ☐ Page 15 – C. Languages and Other Forms of Communication (do NOT complete page 16)
   • ☐ Page 20, Acknowledgment – please complete and have notarized
   • ☐ Page D, Agency´s Officers/Employees/Contractors – complete Officers/Stakeholders information i.e., Program Director information. Do NOT complete page E
   Please read page 19, Schedule 9 – Assurances Please read pages A and B (Definitions) Page C (Application Checklist) does NOT apply)
2. How to complete the Early Intervention PROVIDER AGREEMENT:
   • Your agency must request the Appendix 1 Agreement type to provide care management (service coordination) to children in the Early Intervention Program.
     • ☐ Page 1 –
       • Type or clearly print (black ink only) the full and legal name of your agency
       • NYS Provider ID/State ID – Leave this blank
     • ☐ Page 2 – you must check the box for "Appendix 1 – Payee Provider Agreement/Service Authorizations and Payment"
     • ☐ Signature Page (found at end of Provider Agreement) –
       • Check the YES box found at the top of the signature page indicating you have read and understand your obligations as stated in the Agreement
       • Check/fill in the YES box found at the top of the signature page indicating your agency is requesting the Appendix 1 Agreement (this may already be checked)
       • Complete all the remaining sections including service catchment area(s)
       • An original signature is required (we cannot accept a copy)
3. Where to submit the Application and Provider Agreement:
   • You must submit the following three (3) items to the New York State Department of Health, Bureau of Early Intervention:
     • The original signed and notarized APPLICATION (all pages must be returned. Page 20 must contain an original signature and be notarized)
     • The PROVIDER AGREEMENT. Note – only the following pages need to be submitted – page 1, page 2, and the signature page with an original signature (we cannot accept a copy)
     • Copy(s) of all Business Association Agreements (BAA) that your agency has with lead Health Homes
     Please mail these items together as one packet to:
   NYS Department of Health
   Bureau of Early Intervention
   Provider Approval Unit
   Corning Tower, Room 287
   Empire State Plaza
   Albany, New York 12237–0660
   
   
   If you have any questions, please contact Enrique Johnson or Michele Kohrs at (518) 473–7016, press 1 at the prompts.