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New York State Department of Health, Bureau of Early Intervention

Application for the Approval of Agencies

Application also available in Portable Document Format (PDF)

As Early Intervention Evaluators, Service Coordinators & Service Providers

Version 2018

This application is to be used to apply for approval of agencies as early intervention evaluators, service providers and service coordinators for the statewide Early Intervention (EI) Program under Title II–A of Article 25 of the Public Health Law.

Who May Apply for Approval as an Early Intervention Agency:

A legal business entity authorized to do business in New York State which directly employs EI qualified personnel, and may contract with individual providers which are approved by the Department, for the provision of early intervention program evaluations, service coordination, and/or early intervention services.

Applicants must have an organizational structure that complies with all federal and state statutes and regulations, including practice acts established by the State Education Department Office of Professions.
Applicants must have an Organizational National Provider Identifier (NPI) for the proposed EI agency If the agency does additional business, other than EI, it is recommended that a separate Organizational NPI be obtained specifically for EI services. You can apply for an NPI at https://nppes.cms.hhs.gov/NPPES/Welcome.do.

Suggested Provider Taxonomy:

Service	Organization Provider Type Code	Classification Name – Area of Specialization
Service Coordination	25 Agencies	251B00000X – Case Management and 252Y00000X – Early Intervention Provider Agency
All Other EI Services	25 Agencies	252Y00000X – Early Intervention Provider Agency

**Please print out a copy of your Organizational NPI and submit it along with the Agency Application/Provider Agreement. You must also must submit a copy of notice from the Internal Revenue Service confirming your agency´s Federal Employer Identification Number.

Minimum Agency Staffing Requirements:

Agency must employ a full–time Early Intervention (EI) Program Director who has:
- A minimum of two years full–time or equivalent of experience in an early intervention, clinical pediatric or early childhood education program that includes serving children ages birth to five years of age, provided that the experience includes direct experience in delivering services to children with disabilities and their families and, at least one year of the experience was in the delivery of services to children less than three years of age and their families.
- The Program Director´s duties may include provision of services.
- This individual must be available a sufficient amount of time to develop and ensure implementation of a Program Standards Plan and to ensure that the agency is in compliance with all federal and state requirements.
Agency must employ a minimum of two individuals (excluding the Program Director) who are either recognized as qualified personnel by the EI Program, as defined in 10 NYCRR Section 69– 4.1, or service coordinators meeting the qualifications in 69–4.4; and, each available to provide a minimum of 20 hours per week EI services and/or evaluations and/or service coordination.
The agency must employ Quality Assurance (QA) Professionals.
- A QA Professional is a professional employed by the agency whose responsibilities include monitoring and overseeing implementation of the agency´s quality assurance plan for a particular early intervention service/profession.
- The agency must have a QA Professional for each early intervention service/profession the agency will be providing.
- Each QA Professional must hold a license, certification, or registration for each type of early intervention service/profession/service coordination.
- There does not need to be separate QA Professionals for evaluation and services. For instance, an SLP QA Professional can cover both services and evaluations.
- Dually licensed/certified individuals can hold a dual QA position.
- An individual with a background in service coordination can also be a QA professional for service coordination.
- The agency Program Director and one or both of the minimum two staff can also be designated as a Quality Assurance Professional if they hold the appropriate license/certification for that function.
- The agency owner/operator and the QA professionals should determine the required number of hours necessary for quality assurance professionals to implement a plan to ensure that quality services are being provided by the agency.

Written Plans

The Agency must submit a QA Plan for all services provided by an agency.
The plan should take into account the size of the agency, type of service, location of service, whether contractors or employees, experience of the professionals, requirements of the professions, EI state and federal requirements and in general what is necessary to ensure that quality services are being provided to children and families by the agency.
The plan will be unique to each agency and probably many of the QA practices already exist and will just need to be formalized into the QA plan.
The QA Plan should be submitted with this Agency Application/Provider Agreement, and must be available for review by local or State Early Intervention Program personnel or their designees.

➢ Agencies must have a Program Standards Plan that includes policies and procedures to ensure the following:

services delivered by employees and contractors of the agency are delivered in accordance with federal and state laws and regulations and in compliance with the New York State Department of Health Provider Agreement. Please be aware that an approved EI Agency Provider is responsible for and shall ensure that its employees and Individual Providers under contract with such Agency Provider comply with the provisions of applicable law and regulations, and with the terms of the Provider Agreement with the Department, when delivering evaluations or services on behalf of the Agency Provider.
compliance with policies, procedures, and guidance memoranda issued by the Department that clarifies requirements of law and regulation related to the Early Intervention Program.
provision of services on a twelve–month basis and flexibility in the hours of service delivery including evening and weekend hours;
provision of services that are family–centered;
teaming and communication with parents and other service providers;
clinical mentorship opportunities;
case conferencing and consultation;
opportunities for continuing education and in–service training on policies and procedures related to the Early Intervention Program and Early Intervention Program core competencies;
opportunities for participation in State Department of Health sponsored EI training depending on the professional´s role (e.g., service coordinator, evaluator, service provider);
resolution of questions, concerns, and problems involving parents, county personnel, and other service providers; and,
routine assessment and improvement of the quality of service delivery.

Please submit a summary of the Program Standards Plan and include a table of contents of the completed plan. The entire Program Standards Plan does not need to be submitted, but must be available for review by local or State Early Intervention Program personnel or their designees.

Once approved and entered into an Appendix 1 Agreement, EI regulations require that all EI agencies enroll in Medicaid. An agency must not initiate enrollment in Medicaid as an EI Provider prior to the Department´s direction to do so. While the April 1, 2013 regulations require approved early intervention agencies that have an Appendix Agreement to become enrolled Medicaid providers, this would not affect the rate that you are paid in the Early Intervention Program.

How to Apply for Approval as an Early Intervention Agency:

To obtain approval, the applicant must submit a completed Agency Application/Provider Agreement, including all required schedules and attachments, to the New York State Department of Health (Department).
The Provider Agreement section of the Agency Application/Provider Agreement is in pdf fillable format so that you can type in your information, then save the document to your files. Once saved, you should then print out the Agreement and sign it. Please keep a copy of the Agreement for your records. Where your signature is required, please sign in ink.–First page
– include full name, leave NYS Provider ID/State ID# blank –Second page– Please check the box for Appendix 1, Read all pages of the agreement – these are terms of your agreement– Authorization/signature page – check the "YES" box indicating you understand your obligations as stated in the Provider Agreement, check the "YES" circle where it reads "My request includes the terms outlined in Appendix 1", complete Agency Provider Name, leave NYS Provider ID–State ID blank, in the ´by´ section include your name, complete your Address, circle the county(ies) in which you are available to provide early intervention services, sign where it says Authorized Signature and include your phone number and title
Provide a cover letter which includes the following Agency Provider name, contact person, email address and phone number. This cover letter must also include a statement that this provider is in compliance with federal and state labor standards, tax and finance standards, federal and state early intervention law and regulations, NYSED practice of the professions and (as applicable) with Medicaid standards and requirements.
Provide relevant background information on the agency. Including the agency´s experience in providing early intervention services/IDEA Part C or other programs for families and children with disabilities, birth through three years of age.
Provide information detailing specifically how your agency is "fiscally viable", including how it will maintain maintenance of normal business operations in compliance with federal and state requirements (include an affirmative statement that the applicant is in compliance with state and federal tax and labor rules, regulations and requirements); adequate financial resources to pay any mandatory business fees/expenses including Medicaid enrollment fees; support start–up; and, support at least a minimum three months of operational business expenses including compliance with labors laws and reimbursement to contractors, any business obligations supporting employees and obligations to any subcontractors, regardless of the volume of EI cases. Your agency is expected to have access to sufficient capital or lines of credit to cover operating expenses. Financial viability may be documented through audit reports and financial statements or other means which demonstrate responsibility and viability.
Signatures must be original and the Agency Application, page 20, must be notarized.

The Review of your Agency Application/Provider Agreement for the Approval of Agencies as Early Intervention Evaluators, Service Coordinators & Service Providers:

Staff within the Department´s Bureau of Early Intervention will review the Agency Application/Provider Agreement for completeness.
If the application is incomplete, the application and all attachments may be returned to the applicant with an information sheet stating what additional information is required for approval and the application must be notarized again prior to resubmission.
When an application is determined to be complete, it will be reviewed.
The Department shall consider applications for approval and reapproval utilizing the criteria set forth in 10 NYCRR Section 69–4.
The applicant will receive notification of approval or denial upon completion of the review process via e–mail. *Please note that the approval process may take up to four months after the successful submission of a complete Agency Application/Provider Agreement.
A Provider Agreement with the Department shall be effective for a five (5) year term from the date of approval, unless terminated pursuant to the terms of the Agreement. If an Agency Provider wishes to continue the provision of EI services after the expiration date, the Agency Provider must notify the Department at least ninety (90) days prior to the expiration date. At that time, specific re–approval requirements will be sent to the Agency provider.

The following references may be of assistance when completing this application:

Individuals with Disabilities Education Act (IDEA) Part C (Title 20 USC Sec. 1431 et. seq.) and Title 34 Code of Federal Regulations Part 303 (http://www.ed.gov/about/offices/list/osers/osep/index.html)
Title II–A of Article 25 of the Public Health Law and Title 10 NYCRR Subpart 69–4 (Early Intervention Program State Program Regulations) (http://www.health.ny.gov/community/infants_children/early_intervention/index.htm)
The Office of Children and Family Services provides support for people and organizations that are interested in starting day care programs in their communities: http://ocfs.ny.gov/main/
The New York State Education Department Office of the Professions provides information regarding Corporate Entities for Professional Practice http://www.op.nysed.gov/corp/
The New York State Education Department Office of the Professions provides information regarding New York State Licensed Professions http://www.op.nysed.gov/prof/
The Bureau of Day Care in NYC provides support for people and organizations that are interested in starting day care programs in one of the five boroughs of New York City. Please contact the Bureau of Day Care in NYC at (212) 676–2444.
EI Billing provider (state fiscal agent) Knowledge Base – https://support.eibilling.com/KB/c3/provider.aspx
It is critical that business owners correctly determine whether the individuals providing services are employees or independent contractors.http://www.irs.gov/Businesses/Small–Businesses–%26–Self– Employed/Independent–Contractor–Self–Employed–or–Employee

Application Instructions

The Agency Application/Provider Agreement must be typed or printed neatly in black ink.
Definitions of terms used in this application are included in the back of this application.
All attachments must be numbered and referenced to the appropriate application schedule.
Applicants must complete all required schedules. Specific instructions for completion are on each schedule.
Please review the application for completeness prior to submission. Incomplete applications will be returned.
Only applications with original signatures on all Disclosure Information forms (Schedule 3) will be accepted.
The acknowledgment to the Assurances form (Schedule 9) must be signed and notarized. The Provider Agreement signature page does not need to be notarized.
Keep a copy of your application for your records.
The applicant will receive notification of approval or denial upon completion of the review process.

Submit the original signed and notarized Agency Application/Provider Agreement to:

NYS Department of Health
Bureau of Early Intervention
Provider Approval Unit
Corning Tower, Room 287
Empire State Plaza
Albany, New York 12237–0660

Inquiries concerning this application can be directed to the New York State Department of Health, Bureau of Early Intervention at the above address, by telephone at (518) 473–7016 or by e–mail at provider@health.ny.gov.

New York State Department of Health
Bureau of Early Intervention

Application for the Approval of Agencies as Evaluators,
Service Coordinators & Service Providers

THIS APPLICATION IS FOR APPROVAL OF AGENCIES ONLY ALL ATTACHMENTS MUST BE NUMBERED
AND REFERENCED TO THIS APPLICATION WHERE INDICATED ONLY APPLICATIONS WITH ORIGINAL
SIGNATURES WILL BE ACCEPTED

SCHEDULE 1 – BACKGROUND INFORMATION

A. Applicant Information
Enter the agency´s legal name, NPI number and federal employer identification number. If conducting business under an assumed name (doing business as; e.g., d/b/a), also provide the d/b/a name and the Certificate of Assumed Name. Enter the mailing address of the agency.
Enter the main telephone number for the agency and a fax number, if available. If the address of the main office is different than the mailing address or if files and records are located at a different address than the mailing address, enter that address under office address. Enter an e– mail address.

AGENCY NAME:______________________________________________________________________

NPI#: _______________________________

Federal Employer Identification Number: ____________________________________

d/b/a (where applicable): ___________________________________________________________________

Mailing Address (Street):____________________________________________________________________

City: _____________________ County: ___________________ State: ______________ Zip: ______________

Telephone #: (_____)__________________ Fax #: (_____)___________________

Office Address (location of files and records):

________________________________________________________________________________________

E–mail Address:________________________________________

Has this agency ever been previously approved by the Department of Health or other state agency, to deliver early intervention evaluations, service coordination or services under this name or d/b/a or NPI number?
☐ Yes ☐ No
Has this agency ever been previously approved by the Department of Health or other state agency to deliver early intervention evaluations, service coordination or services under a different name or organizational structure?
☐ Yes ☐ No
If yes, complete all information requested below pertaining to that agency.

Name of entity	Type of entity
Address (include county)	Date of Ownership From (date) _____/_____ /_____ To (date) _____/_____ /_____ Type of Ownership/Interest:
Current status of entity (check one) ☐ Open ☐ Closed
State agency approval of entity (Check all that apply) ☐ Department of Health ☐ State Education Department ☐ Office of Mental Health ☐ Office of People with Developmental Disabilities

B. Designated EI Program Director
Enter the name, title, address, telephone number and e–mail address of the full–time EI Program Director for the agency. This person must be an employee or owner of the agency.

Name (Mr., Mrs., Ms, Miss, Dr.): __________________________________________________________

Title:__________________________________________

Address (if different from above):

___________________________________________________________________________________

Telephone #: (_____)__________________ E–mail Address: ______________________________________

C. Board Resolution
Corporate applicants must attach a copy of a board resolution authorizing the agency to submit this application. Public applicants must attach a resolution from the local legislature, board of supervisors or other governing body having jurisdiction over the applicant agency authorizing an individual to submit this application. (Attachment # __________________)

SCHEDULE 2 – Corporate Structure/Disclosure Requirements

A. Type of Ownership
Check the box that indicates the Type of Ownership of the applicant agency. Attach a certified copy of the Assumed Name Certificate (d/b/a). Certified copies are required, such documents can be obtained by the issuing agency, either the New York State Department of State, Division of Corporations, 41 State Street, Albany, New York 12231 or the county clerk´s office in which the business is located.

☐ Sole Proprietor
1. The sole proprietor must complete Schedule 3 – Disclosure Information.
2. The EI Program Director must complete Schedule 3 and attach a resume detailing experience in early intervention, clinical pediatric or early childhood education programs that include children with special needs.
3. Attach a certified copy of the Assumed Name Certificate. (Attachment #________).
☐ Partnership
1. Each partner must complete Schedule 3 – Disclosure Information.
2. The EI Program Director must complete Schedule 3 and attach a resume detailing experience in early intervention, clinical pediatric or early childhood education programs that include children with special needs.
3. Attach a photocopy of the applicant´s fully executed Partnership Agreement. (Attachment #________).
4. Attach a certified copy of the Assumed Name Certificate. (Attachment #________).
☐ Professional Limited Liability Company (PLLC)
1. Each officer of the applicant PLLC must complete Schedule 3 – Disclosure Information.
2. The EI Program Director must complete Schedule 3 and attach a resume detailing experience in early intervention, clinical pediatric or early childhood education programs that include children with special needs.
3. Attach a list of all the PLLC´s members´ names and date of birth. (Attachment #________).
4. Attach a photocopy of the applicant´s fully executed Articles of Organization and filing receipt. (Attachment #________).
5. IF applicable, attach the Certificate of Assumed Name
☐ Limited Liability Partnership (LLP)
1. Each partner must complete Schedule 3 – Disclosure Information.
2. The EI Program Director must complete Schedule 3 and attach a resume detailing experience in early intervention, clinical pediatric or early childhood education programs that include children with special needs.
3. Attach a photocopy of the applicant´s fully executed Partnership Agreement. (Attachment #________).
4. Attach a photocopy of the applicant´s fully executed Certificate of Limited Partnership and filing receipt. (Attachment #________).
5. IF applicable, attach the Certificate of Assumed Name
☐ Not–For–Profit Corporation
1. Each officer must complete Schedule 3 – Disclosure Information.
2. The EI Program Director must complete Schedule 3 and attach a resume detailing experience in early intervention, clinical pediatric or early childhood education programs that include children with special needs.
3. Attach a list of all the corporation´s board members´ names and date of birth. (Attachment #________).
4. Attach a certified copy of the Certificate of Incorporation, and filing receipt. (Attachment #________).
5. IF applicable attach the Certificate of Assumed Name
☐ Business Corporation
1. Each officer and principal stockholder (holder of 10% or more of the issued and outstanding stock) must complete Schedule 3 – Disclosure Information.
2. The EI Program Director must complete Schedule 3 and attach a resume detailing experience in early intervention, clinical pediatric or early childhood education programs that include children with special needs.
3. Attach a list of all the corporation´s board members´ names and date of birth. (Attachment #________).
4. Attach a certified copy of the Certificate of Incorporation, and filing receipt. (Attachment #________).
5. IF applicable attach the Certificate of Assumed Name
☐ Professional Corporation (PC)
1. Each officer of the corporation must complete Schedule 3 – Disclosure Information.
2. The EI Program Director must complete Schedule 3 and attach a resume detailing experience in early intervention, clinical pediatric or early childhood education programs that include children with special needs.
3. Attach a list of all the corporation´s board member´s names and date of birth. (Attachment #________).
4. Attach a certified copy of the Certificate of Incorporation and filing receipt. (Attachment #________).
5. IF applicable attach the Certificate of Assumed Name
☐ Limited Liability Company (LLC)
1. Each officer of the applicant LLC must complete Schedule 3 – Disclosure Information.
2. The EI Program Director must complete Schedule 3 and attach a resume detailing experience in early intervention, clinical pediatric or early childhood education programs that include children with special needs.
3. Attach a list of all the LLC´s members´ names and date of birth. (Attachment #________).
4. Attach a photocopy of the applicant´s fully executed Articles of Organization and filing receipt. (Attachment #________).
5. IF applicable, attach the Certificate of Assumed Name
☐ Government Subdivision
1. Authorized individual must complete Schedule 3 – Disclosure Information.
2. The EI Program Director must complete Schedule 3 and attach a resume detailing experience in early intervention, clinical pediatric or early childhood education programs that include children with special needs.

B. Foreign Entities
Foreign entities are those already formed in another state that may apply for authority to conduct business in New York State. In addition to the documentation required in Section A, foreign entities must provide:

Schedule 3 – Disclosure Information as required for the type of organizational structure noted above (e.g., sole proprietorship, partnership, PLLC, LLP, Not– For–Profit Corporation, Business Corporation, PC, LLC or Government Subdivision).
The EI Program Director must complete Schedule 3 and attach a resume detailing experience in early intervention, clinical pediatric or early childhood education programs that include children with special needs.
Attach a copy of the Application for Authority to Do Business in New York and the Department of State filing receipt. (Attachment #________).

C. Parent Organization Information
For all organizations with a parent organization, complete related organization information as indicated. A parent organization is any entity that wholly owns or has a majority interest in the applicant entity.

List the full legal name, addresses of the principal office and place of doing business and Federal Employee Identification Number (FEIN) of any parent organization. (Attachment #________).
For each parent organization identified in C 1:
1. List the full name and title of each member of the Board of Directors, board officers, principal stockholders or sponsors of such parent organization. (Attachment #________).
2. List the full legal name and the addresses of the principal office and place of doing business of any agencies or facilities owned or operated by the parent organization or subsidiary corporation that are certified or licensed for the provision of health or human services or educational services, including preschool programs for children with disabilities. (Attachment #________).
Describe in detail the relationship between the applicant agency and any parent organization, including the method or mechanism by which control over the applicant agency is or will be effectuated (e.g. stock ownership, membership arrangement, common officers, directors or stockholders or other arrangement). (Attachment #________).

SCHEDULE 3 – DISCLOSURE INFORMATION – all three pages must be completed by each individual identified in Schedule 2. This form may be duplicated as necessary.

A. Personal Information

Has five percent or more of an interest or voting rights in the applicant agency? Yes ☐ No ☐

If yes, indicate percentage: _____________

Name (Mr., Mrs., Ms, Miss, Dr.): Date of Birth: ____/____/________

___________________________________________________________________ SS#:_______–_______–_______

Title (Eg. CEO, CFO, Executive Director, Program Director):__________________________________________________

Address: ________________________________________________________________________________________
Street City County Zip

Email: ______________________________________ Telephone #: (_____)__________________

B. Licenses/Certificates Held

Enter information regarding professional license(s) or teacher certification.

Check if not currently registered or certified: NONE:_____

Name of Profession:	NYS License/Certification No:
Dates of Registration/Certification: From: _____/_____ /_____ To: _____/_____ /_____ Permanent: ______________
Name of Profession:	NYS License/Certification No:
Dates of Registration/Certification: From: _____/_____ /_____ To: _____/_____ /_____ Permanent: ______________

Has your professional license, registration or certification ever been suspended or revoked?
Yes ☐ No ☐
If "yes", attach a separate sheet providing the following information:
1. Date(s) of action(s) and Reason(s) for action(s)
2. Resolution of action(s) (include corrective action that was taken and whether approval has been reinstated)
3. Date of reinstatement

C. Offices/Positions Held in Health or Human Service Agencies/Facilities

Enter information regarding any offices/positions held in other health or human service agencies or facilities, including early intervention and/or special education preschool programs, over the past ten (10) years. Attach additional sheets if necessary (Attachment #________)

None: ___________

Name of Facility/Agency	Office/position held: From: _____/_____/_____ to: _____/_____/_____
Address:
Name of Facility/Agency	Office/position held: From: _____/_____/_____ to: _____/_____/_____
Address:

D. Record of Legal Actions

Except for minor traffic violations, have you ever been convicted of any violation of the law (e.g., criminal, civil, or administrative charges)?
No ☐ Yes ☐
Have you or any agency that provides health and human services in which you held an office or position ever been restricted, suspended, revoked or fined by any Federal, State or local agency?
No ☐ Yes ☐
Have you or any agency that provides health and human services in which you held an office or position ever been subject to an audit that resulted in recoupment?
No ☐ Yes ☐
Have you or any agency that provides health and human services in which you held an office or position ever had a contract terminated, suspended or restricted for failure to perform or for any other reason?
No ☐ Yes ☐
Has the applicant agency ever been the subject of any child care enforcement actions (e.g., fines, sanctions, etc) or had its approval, certification, or licensure restricted, revoked or suspended by the Office of Children and Family Services?
Have you ever been restricted, suspended or excluded from participation as a Medicaid provider?
No ☐ Yes ☐
Are there any criminal, civil or administrative charges pending against you?
No ☐ Yes ☐

If the answer to any of these questions is "yes", complete the following for each action. Attach additional sheet(s) as necessary. Submit a copy of the certificate of disposition and a brief statement of circumstances. (Attachment #________)

Date of Action _____________ Type of Action ________________________________

Location ______________________________________________________________

Explanation of Violation ___________________________________________________________________________

E. Ownership/Interest in any other entity

Enter the name, address and other data indicating other health or human service agencies or facilities you have owned or had a controlling interest in over the past ten (10) years. Include all entities that were approved to provide early intervention or early childhood services. Attach additional sheets, if necessary (Attachment #________)

None: ___________

Name of entity	Type of entity
Address	Date of Ownership From (date) _____/_____ /_____ To (date) _____/_____ /_____ Type of Ownership/Interest:
Current status of entity (check one) ☐ Open ☐ Closed ☐ Proposed
State agency approval of entity (Check all that apply) ☐ Department of Health ☐ State Education Department ☐ Office of Mental Health ☐ Office of People with Developmental Disabilities ☐ Office of Children and Family Services ☐ Office of Alcohol and Substance Abuse Services

F. Certification

The Certification must contain the signature of the individual named in Schedule 3 A.
The undersigned hereby certifies under penalty of perjury that the information contained in Schedule 3, and all attachments to Schedule 3 herein, is accurate, true and complete in all material respects.

__________________________________________________ Title _________________________________
Print Name

__________________________________________________ Date __________________________________
Signature

SCHEDULE 4 – APPLICANT AGENCY AFFILIATION

A. Health, Education, Developmental Disabilities, and Mental Hygiene Agencies

Please complete the following questions regarding the applicant agency´s affiliation with other government entities. Please answer all questions.

Is the applicant agency currently approved, certified or licensed by any of the following state agencies for services other than early intervention? Check below to indicate status and if yes, provide the license or certification number, if any.
1. New York State Department of Health ☐ No ☐ Yes
  - [ ] Article 28 PHL Diagnostic and Treatment Center # ____________
  - [ ] Article 28 PHL Hospital Based Outpatient Clinic # ____________
  - [ ] Article 36 CHHA (Certified Home Health Agency) # ____________
  - [ ] Article 36 LHCSA (Licensed Home Care Service Agency) # ____________
  - [ ] Approved Medicaid Provider # ____________
    (If more than one Medicaid Provider number, provide all numbers.)
2. State Education Department ☐ No ☐ Yes
  - [ ] Section 4410 Education Law # ____________
  - [ ] BOCES/School District # ____________
  - [ ] VESID # ____________
3. Office of People with Developmental Disabilities ☐ No ☐ Yes
  - [ ] Article 16 OPWDD Clinics # ____________
  - [ ] Comprehensive Medicaid Case Management # ____________
4. Office of Mental Health ☐ No ☐ Yes
  - [ ] Article 31 MHL Clinics # ____________
5. Office of Alcohol and Substance Abuse Services ☐ No ☐ Yes
  - [ ] Article 22 Service Provider # ____________
If "yes" to any of the above, provide the date of the most current site visit, program review and, if applicable, audit by the relevant government agency(ies). Attach additional sheets if necessary (Attachment #________)

State Agency _______________________________________ Date of Review: ____/____/_______

State Agency _______________________________________ Date of Review: ____/____/_______
Has the applicant agency ever been the subject of any enforcement actions (e.g., fines, sanctions, etc) or had its approval, certification or licensure restricted, revoked or suspended by any of the above State agencies? ☐ No ☐ Yes

If "yes" attach separate sheet providing the following information:
1. Dates of action
2. Reason(s) for action
3. Resolution of action (include corrective action that was taken and whether approval has been reinstated) (Attachment #________)

B. Managed Care Plan Affiliations

List all managed care plans that recognize the agency as an approved or in–network provider. (Attachment #________)

SCHEDULE 5 –PERSONNEL

A. Available Personnel

In addition to the early intervention program director, there must be a minimum of two employed qualified personnel (QP) or service coordinators who meet qualifications as required by 10NYCRR 69–4. The two QP must provide evaluations, service coordination, or services to individuals with disabilities for a minimum of twenty hours each per week.

Complete the chart below, indicating the number of personnel that the agency intends to use to provide early intervention services.

Profession	Directly Employed	Available by Contract (must be state approved)
Audiology:
Audiologist
Medical/Nursing:
Pediatrician
Physician other than Pediatrician
Physician Assistant *		Cannot be contracted for professional services
Nurse Practitioner
Registered Nurse
Licensed Practical Nurse*		Cannot be contracted for professional services
Nutrition:
Certified Dietitian/Nutritionist
Registered Dietitian
Occupational Therapy:
Occupational Therapist
Occupational Therapy Assistant *		Cannot be contracted for professional services
Physical Therapy:
Physical Therapist
Physical Therapist Assistant *		Cannot be contracted for professional services
Psychology:
Licensed Psychologist
School Psychologist
Social Work:
Licensed Master Social Worker
Licensed Clinical Social Worker
Speech Pathology:
Speech–Language Pathologist
Special Education:
Teacher of Special Education
Teacher of Students with Disabilities (Birth – Grade 2)
Teacher of Blind and Partially Sighted
Teacher of Blind and Visually Impaired
Teacher of Deaf and Hearing Impaired
Teacher of Deaf and Hard of Hearing
Teacher of Speech and Hearing Handicapped
Teacher of Speech and Language Disabilities
Vision Services:
Certified Orientation and Mobility Specialist
Certified Low Vision Specialist
Fellows of the College of Optometrists in Vision Development (FCOVD)
Optometrist
Service Coordination Services:
Service Coordinators**		Cannot be contracted

*These professionals can only provide early intervention services in an employment setting with appropriate supervision, with the exception of service coordination services.

**Use this category for service coordinators who are not in one of the professions otherwise listed in schedule 5.

*** Per 10NYCRR 69–4.9a, these individuals must be directly employed and supervised by the approved agency.

It is critical that business owners correctly determine whether the individuals providing services are employees or independent contractors. Visit the IRS website for information.

B. Personnel Information

All agencies must have, in addition to the early intervention program director, a minimum of two qualified personnel or service coordinators who meet qualifications as required by 10NYCRR Section 69–4, each of whom provides evaluations, service coordination, or services to individuals with disabilities for a minimum of twenty hours each per week.

All contracted individuals and all contracted agencies MUST be approved by the New York State Department of Health Early Intervention Program to deliver early intervention services. All names listed on this form as "Available by Contract" will be verified for NYSDOH approval to provide early intervention services.

All agencies must have a Quality Assurance Professional for each early intervention service/profession. Each Assurance Professional must hold a license, certification, or registration for each type of early intervention service/profession/service coordination. There does not need to be separate QA Professional for evaluation and services.

Please note that your agency cannot be approved to provide Core Evaluations, unless your agency´s available personnel consists of two or more qualified personnel from different disciplines who are trained to utilize appropriate methods and procedures, have sufficient expertise in child development, and at least one of whom shall be a specialist in the area of the child´s suspected delay or disability. For each of the following personnel categories, attach a list that includes the following:

Directly employed individuals that deliver early intervention services (include name, address, phone number, e–mail address, National Provider Identifier, social security number, profession and include the license/certificate number for each individual). Specify which of these individuals listed is the Quality Assurance Professional(s) licensed or certified in that profession (one is needed for EACH profession listed) (Attachment #________). Please utilize the attached document entitled: Agency´s Officers/Employees/Contractors.
Contracted individuals that deliver early intervention services (include name, address, phone number, email address, EI Provider ID number, National Provider Identifier, profession, and include the license/certificate number for each individual) (Attachment #________). Please utilize the attached document entitled: Agency´s Officers/Employees/Contractors.

Once approved, the AGENCY is responsible for adding and maintaining ALL employees/contractors on the New York Early Intervention System (NYEIS) data system.

SCHEDULE 6 – SERVICE AVAILABILITY

A. Services

Check the early intervention service types for which you are seeking approval (see Definitions).

Please check all that apply.

☐ Core Evaluations (Enclose physician letter; see Application Checklist on last page).
☐ Supplemental Evaluations
☐ Service Coordination Services
☐ Home/community–based individual/collateral visits
☐ Parent–child groups
☐ Group developmental intervention
☐ Family/caregiver support group

☐ Check this box only if you will be providing any of the above services at a site you rent, own, lease or operate. If box is checked you must complete Schedule 7.

Submit a Quality Assurance Plan for each type of service offered by the agency, including evaluations and service coordination. Identify a professional or professionals who hold a license, certification, or registration in the type of service offered by the agency whose responsibilities include monitoring and overseeing implementation of the quality assurance plan for that service. (Attachment #________)

B. Languages and Other Forms of Communication

Circle the languages and other forms of communication that can be used by agency staff that provide early intervention services. English is assumed, and therefore, not listed.

Afghanistan	Gujarati	Polish
Albanian	Haitian-Creole	Portuguese
American Sign	Hakka	Punjabi
Arabic	Hebrew	Romanian
Armenian	Heisch	Russian
Asian	Hindi	Seneca
Belorussian	Hungarian	Senegal
Bengali	IBGO(Nigerian)	Serbian
Bulgarian	IBO(African)	Sindhi
Cambodian	Ilocano	Sinhalese
Cantonese	Indian	Slavic
Carib/Cariban	Iranian	Spanish
Chinese	Italian	Swahili
Croatian	Japanese	Swedish
Czech	Kamir	Tagalog
Danish	Karen	Taiwanese
Dutch	Korean	Tamil
Edo	Kudjarti	Thai
Estonian	Lao	Toisanese
Ethiopian	Lithuanian	Turkish
Farsi	Macedonian	Ukrainian
Filipino	Malay	Urdu
Finnish	Mandarin	Vietnamese
French	Marathi	Visayan
Fulani	Mohawk	Wolof
Georgian	Norwegian	Yiddish
German	Other	Yoruba
Greek	Persian

C. Specialized Services

Can you provide specialized services for specific populations of infants and toddlers?

☐ Yes ☐ No

If yes, please circle the population type(s) below.

Apraxia

Auditory Processing Disorder

Autism/PDD

Cerebral Palsy

Communication Disorders

Down Syndrome

Dyspraxia

Feeding/Swallowing Disorders

Fetal Alcohol Syndrome

Hearing Loss

Intellectual Disability

Medically Complex

Motor Disorders

Oral Motor Disorders

Prematurity

Psychiatric/Behavioral/Emotional Disorders

Seizure Disorders

Sensory Integration Disorders

Traumatic Brain Injury

Vision Impairments

Other

SCHEDULE 7 – FACILITY SITES

Complete a copy of this schedule for each facility site operated by the applicant agency.

Name/Address of Site

Name (if different than agency name)
_________________________________________________________________________________________________________
Site Address
__________________________________________________________________________________________________________
City County Zip Telephone ( )
__________________________________________________________________________________________________________

Early Intervention Service Model Options

Check the early intervention service model options that you are seeking to provide at this site:

☐ Evaluations
☐ Facility–based individual/collateral visits
☐ Parent–child groups
☐ Group developmental intervention
☐ Family/caregiver support group

Health and Safety Policy

The agency must provide assurances that it will be in compliance with all local fire, health and safety codes; will employ a policy for addressing health, safety and sanitation issues (including diapering, handwashing, and food preparation) that conform to standards established by the Department; and is in compliance with the Americans with Disabilities Act. In addition, the applicant must submit the following for this site:

A building inspection by local authorities from the last 12 months and either a copy of the Certificate of Occupancy or Certificate of Compliance. Documentation must be specific to the purpose of providing services to children at that site (Attachment #________)
A fire evacuation plan, site diagram and a fire inspection report from the last 12 months. The site diagram must also include handwashing, diapering, bathrooms, and food preparation/storage areas. (Attachment #________)
Procedures to ensure the availability of staff to administer cardiopulmonary resuscitation (CPR) and first aid. Include copy(ies) of CPR certification. (Attachment # ________)

Child Care Providers

Individuals Providing Services Outside of New York City

Do you now or do you intend to provide care at this site to three or more children together for more than three hours per day per child?
☐ No ☐ Yes
If yes, is the site registered or licensed by the Office of Children and Family Services (OCFS) to deliver child care services?
☐ No ☐ Yes (please provide type of daycare and registration license number below)

Type: License # __________________________________

If you are not a licensed child care provider but answered yes to (1) above, you should contact the Office of Children and Family Services regarding obtaining licensure as a child care provider

If "yes" to (2) above, provide the date of the most current site visit, program review or audit by the Office of Children and Family Services:
Date of Review: _____/_____/_____

Individuals Providing Services in New York City

Do you now, or do you intend to provide care at this site, to seven or more children together for five or more hours per week?
☐ No ☐ Yes
If yes, are you licensed by the New York City Department of Health and Mental Hygiene to deliver day care services at this site?
☐ No ☐ Yes

If yes, provide your permit number below and append a copy of your permit:

Permit # ________________________________________________

If you are not a licensed day care provider but answered yes to (1) above, you should contact the New York City Department of Health and Mental Hygiene regarding obtaining licensure as a day care provider.

If "yes" to (2) above, provide the date of the most current site visit, program review or audit by the New York City Department of Health and Mental Hygiene:
Date of Review: _____/_____/_____

SCHEDULE 9 – ASSURANCES

The applicant assures the Commissioner of Health and, if applicable, the Commissioner of Education, of compliance during the term of approval with all requirements under Title II–A of Article 25 of the Public Health Law; 10 NYCRR: Subpart 69–4; Part C of the Federal Individuals with Disabilities Education Act and 34 CFR Part 303.

The applicant assures that the agency will abide by department policies as stated in guidance issued by the Department that clarifies requirements of law and regulation related to the Early Intervention Program.
The applicant assures that the agency is appropriately staffed with qualified personnel with state licensure or certification as appropriate, and maintains a copy of current registration or certification for those personnel;
The applicant assures that when contracting, the agency will contract only with state–approved individual or agency early intervention providers;
The applicant assures that agency personnel have access to, and participate in, ongoing in–service training on the delivery of early intervention services;
The applicant assures that the agency has the capacity to and will provide services to children in accordance with IFSPs and in natural settings to the maximum extent appropriate;
The applicant assures that the agency has the capacity to deliver services on a twelve–month basis and to provide flexibility in hours of service delivery, including weekend and evening hours;
The applicant assures that the agency has the capacity to deliver all approved service model options applied for in this application.
The applicant assures that the agency is in compliance with all local fire, health and safety codes; that the agency employs a policy for addressing health, safety and sanitation issues that conforms with standards established by the Department; and, where applicable, is in compliance with the Americans with Disabilities Act;
The applicant assures that agency personnel will immediately notify the Early Intervention Official if s/he becomes aware of any health or safety hazard posed in community–based settings where s/he is providing parent–child groups, family support groups, or group developmental interventions;
The applicant assures that it will comply with the confidentiality requirements as set forth in federal and state statute and regulation; and,
The applicant assures that it will request, in writing, approval from the State Agency granting approval, if the agency wishes to modify any of the information contained in this application, including qualified personnel available to deliver services or service models provided or transfers, assignments, or other dispositions of less than ten percent of an interest or voting rights of the agency.
The applicant assures that if the agency intends to cease services or intends to cease ownership, possession or operation of the agency, or chooses to voluntarily terminate status as an approved provider, the agency will submit to the Department and early intervention official written notice of such intention and a plan for transition of children not less than 90 days prior to the intended effective date of such action.

ACKNOWLEDGMENT

I, the undersigned, hereby certify under penalty of perjury, that I am duly authorized to subscribe and submit this application and that the information contained herein and attached hereto, with the exception of those schedules pertaining to personal and disclosure information which must be individually certified, is accurate, true and complete in all material aspects. I further acknowledge that the application will be processed pursuant to the provisions of Title II–A of Article 25 of the Public Health Law, and the pertinent regulations adopted thereto.

________________________________________________________________              _______________________________
Print Name (Mr. Mrs., Ms., Dr.)                                                                                                                 Title

________________________________________________________________              ________________________________
Signature                                                                                                                                                     Date

Notarization

State of New York )
SS:
County of )
On this _________ day of _______________, 20___, before me personally appeared _________________________________ residing at
                                                                                                                                                            (Name)
_______________________________________________ to me known and known by me to be ___________________________________
             (Street, City, State, Zip)                                                                                                                                  (Title)

of _____________________________________ and the person who executed this Agency Application in the name of said
                 (Corporation/Agency)
_____________________________________ and (s)he duly acknowledged to me that (s)he executed the same as and for the
             (Corporation/Agency)
act and deed of said ________________________________________________________.
                                                         (Corporation/Agency)

NOTARY STAMP                                                                     ________________________________________________
                                                                                                                                                        Notary Public Signature

Definitions

Term	Definition
Agency	"Agency" means an entity which employs qualified personnel, and may contract with individual providers or other agencies which are approved by the Department, for the provision of early intervention program evaluations, service coordination, and/or early intervention services.
Agency Program Director	A professional with specific experience as required by 10NYCRR 69–4.5(a)(4)(viii)(a) and employed on a full–time basis whose duties may include early intervention program service delivery in addition to administration and oversight responsibilities.
Applied behavior analysis (ABA)	ABA means the design, implementation, and evaluation of systematic environmental changes to produce socially significant change in human behavior through skill acquisition and the reduction of problematic behavior. ABA includes direct observation and measurement of behavior and the identification of functional relations between behavior and the environment. These include contextual factors such as establishing operations, antecedent stimuli, positive reinforcers, and other consequences that are used to produce the desired behavior change.
Available by Contract	A contractor is a provider. See definition of provider. A contractor is independent and responsible for delivering a service. A contractor does not receive wages, and generally receives an IRS form 1099 at the end of the year. Refers to individual qualified personnel available to an agency or municipality through a contractual agreement. An individual under contract is not employed by an agency
Catchment Area	Counties for which the agency has the availability to provide early intervention services.
Employed	Refers to personnel directly employed by an agency. Employees´ duties are defined by, directed by and, supervised by the agency. An employee receives wages and at the end of the year an employee receives an IRS wage and tax statement (W–2).
Facility Site	A site operated by an agency seeking early intervention approval where children receive early intervention evaluations or services.
Facility–based Individual Collateral Visits	The provision by appropriate qualified personnel of early intervention services to the child and/or parent or other designated caregiver at an approved early intervention provider´s site.
Family/caregiver Support Group	The provision of early intervention services to a group of parents, caregivers (foster parents, day care staff) and/or siblings of eligible children for the purposes of: (a) enhancing their capacity to care for and/or enhance the development of the eligible child; and (b) providing support, education, and guidance to such individuals relative to the child´s unique developmental needs.
Group Developmental Intervention	The provision of early intervention services by appropriate qualified personnel to a group of eligible children at an approved provider´s site or in a community–based setting where children under three years of age are typically found (this group may also include children without disabilities).
Home and Community– based Visits	The provision by appropriate qualified personnel of early intervention services to the child and/or parent or other designated agency at the child´s home or other natural environment.
Individual Provider	"Individual" means a person who holds a state–approved or recognized certificate, license, or registration in one of the disciplines set forth in early intervention regulations and is under contract with either a municipality or an agency provider. This person is not an employee.
Multidisciplinary Evaluation	The procedures used by appropriate qualified personnel to determine a child´s initial and continuing eligibility for the Early Intervention Program, including determining the status of the child in each of the following areas of development: cognitive, physical, communication, social or emotional, and adaptive development. Multidisciplinary evaluations can be comprised of: Core Evaluations: consists of two or more qualified personnel from different disciplines who are trained to utilize appropriate methods and procedures, have sufficient expertise in child development, and at least one of whom shall be a specialist in the area of the child´s suspected delay or disability; and, must include a developmental assessment; a review of pertinent records and a parent interview as specified in regulations and may include a family assessment. Supplemental Evaluations: Include physician and non–physician evaluations provided upon the recommendation of the multi–disciplinary team conducting the core evaluation and with the agreement of the parent. A supplemental evaluation may also be provided in conjunction with the core evaluation by a specialist trained in the area of the child´s suspected delay or disability.
Natural Environments	Settings which are natural or normal for the child´s age peers who have no disability, including the home, a relative´s home when care is delivered by the relative, child care setting, or other community settings in which children without disabilities participate.
Parent–child Groups	A group comprised of parents or caregivers, children, and a minimum of one appropriate qualified provider of early intervention services at an early intervention provider´s site or community based setting (e.g., day care center, family day care, or other community settings).
Provider	"Provider" means an agency or individual approved in accordance with section 69–4.5 of EI regulations to deliver service coordination, evaluations, and/or early intervention services.
Qualified Personnel	Individuals with the appropriate licensure, certification or registration in the area in which they are providing services. A list of such personnel can be found in early intervention regulations 10NYCRR 69–4.1(aj) and are either individuals who are approved by the State Department of Health and under contract with an agency provider or employed by agency providers.
Quality Assurance Professional	A Quality Assurance Professional is a professional employed by the agency whose responsibilities include monitoring and overseeing implementation of the agency´s quality assurance plan for a particular early intervention service/profession.
Required Employee	A minimum of two qualified personnel or service coordinators who meet qualifications as required by 10 NYCRR, in addition to the early intervention Program Director, each of whom provides evaluations, service coordination, or services to individuals with disabilities for a minimum of twenty hours each per week, plus designated Quality Assurance Professionals.
SED Waiver	See the websites below for information on the State Education Department Waiver: www.op.nysed.gov/waiver–ei–info.htm www.op.nysed.gov/waiver–ei–faq.htm
Service Coordination	Includes assistance and services provided by a service coordinator to enable an eligible child and the child´s family to receive the rights, procedural safeguards and services that are authorized under the Early Intervention Program.
Specialized Services	Expertise providing services to a specific population of children and/or families; e.g., children with autism, children with cerebral palsy .

APPLICATION CHECKLIST

☐ Make a copy of this application for your records.
☐ Federal employer (tax) identification number must appear on each page of the application, include a copy of notice from the IRS confirming your agency´s FEIN number.
☐ Include copy of your National Provider Identifier from https://nppes.cms.hhs.gov/NPPES/Welcome.do
☐ The agency´s Quality Assurance plan, including the Quality Assurance Professionals for each service type your agency will be providing.
☐ A summary of the Program Standards Plan, including the plan´s table of contents.
☐ Copies of all organizational documents, such as partnership agreements or certificates of Incorporation and filing receipts must be enclosed with this application.
☐ Verify that all Qualified Personnel providing services under contract have current state Approval to provide early intervention services.
☐ Submit a list of all providers (contracted individuals and employees), including their name, address, phone number, e–mail address, National Provider Identifier, social security number, profession, and include licenses/certificates numbers via the attached document entitled: Agency´s Officers/Employees/Contractors.
☐ If CORE Evaluation services is checked, a letter from a NYS licensed and registered Physician on their letterhead must be enclosed. The letter should state that the physician will perform physical exams as needed for the agency.
☐ If you are seeking to provide facility–based services, Schedule 7 must be completed for each Site. Copies of health, safety, and fire evacuation policies, Certificate of Occupancy and Assurance of ADA compliance must be enclosed for each site.
☐ All Schedules must have original signatures, be dated and returned with the application.

Failure to submit all required attachments and a fully completed application will result in the application being returned to the applicant for re–submission. All required Schedule 3 Disclosure Information forms must be submitted by the applicant with the application.

NYS Department of Health Bureau of Early Intervention
Provider Approval and Due Process Unit
Agency´s Officers/Employees/Contractors

As part of your Agency´s approval to provide early intervention services we will be establishing, in our database (NYEIS), an initial listing of Officers/Stakeholders and Employees/Contractors. Please complete and return via fax (518–486–1090)–Attention: Kelly Callahan

Officers/Stakeholders

First Name:
Last Name:
Social Security Number: Date of Birth:
NPI*:
Phone Number: Fax Number: Address:
E–mail:
Providing Services: Yes or No
Professional License/Certification:
License/Certification Number:
Are they the Agency´s Quality Assurance Staff for this Profession: Yes or No
First Name:
Last Name:
Social Security Number: Date of Birth:
NPI*:
Phone Number: Fax Number: Address:
E–mail:
Providing Services: Yes or No
Professional License/Certification:
License/Certification Number:
Are they the Agency´s Quality Assurance Staff for this Profession: Yes or No
First Name:
Last Name:
Social Security Number: Date of Birth:
NPI*:
Phone Number: Fax Number: Address:
E–mail:
Providing Services: Yes or No
Professional License/Certification:
License/Certification Number:
Are they the Agency´s Quality Assurance Staff for this Profession: Yes or No

If needed make additional copies.

Employees/Contractors Available to Provide Direct Services:

First Name:
Last Name:
Social Security Number:
NPI*:
Address:
Employee or Contractor:
Professional License/Certification:
License/Certification Number:
Are they the Agency´s Quality Assurance Staff for this Profession: Yes or No
Service Coordinator Qualifying Education/Experience (if applicable):
- Bachelor´s degree in a health/human service field
- One year of SC experience and an Associates Degree in a health/human service field
- One year SC experience and one year experience in a service setting with infants/toddlers with developmental delays or disabilities
- Two years SC experience
Additional License/Certification:
Languages Spoken Other Than English:
First Name:
Last Name:
Social Security Number:
NPI*:
Address:
Employee or Contractor:
Professional License/Certification:
License/Certification Number:
Are they the Agency´s Quality Assurance Staff for this Profession: Yes or No
Service Coordinator Qualifying Education/Experience (if applicable):
- Bachelor´s degree in a health/human service field
- One year of SC experience and an Associates Degree in a health/human service field
- One year SC experience and one year experience in a service setting with infants/toddlers with developmental delays or disabilities
- Two years SC experience
Additional License/Certification:
Languages Spoken Other Than English:
First Name:
Last Name:
Social Security Number:
NPI*:
Address:
Employee or Contractor:
Professional License/Certification:
License/Certification Number:
Are they the Agency´s Quality Assurance Staff for this Profession: Yes or No
Service Coordinator Qualifying Education/Experience (if applicable):
- Bachelor´s degree in a health/human service field
- One year of SC experience and an Associates Degree in a health/human service field
- One year SC experience and one year experience in a service setting with infants/toddlers with developmental delays or disabilities
- Two years SC experience
Additional License/Certification:
Languages Spoken Other Than English:

If needed make additional copies.

New York State Department of Health
Bureau of Early Intervention

Early Intervention Provider Agreement

This Provider Agreement is entered into by and between the New York State Department of Health (hereinafter referred to as the "Department"), and
______________________________________________________________________________________________________________
[NYS Provider ID/State ID] ____________________________________ (hereinafter referred to as the "Provider"). Provider acknowledges that this agreement is made by and between the Department and Provider, as Provider is currently organized and constituted or presented. The Department reserves the right to terminate this agreement should the Provider reorganize or otherwise substantially change the character of its corporate or other business structure or presentation.

Purpose of Agreement

The purpose of this Agreement is to set forth the terms and conditions for participation in the Early Intervention Program (EIP) and to establish the obligations, expectations and relationship between the Department, municipalities within the State and the Provider.

Providers intending to receive service authorizations for early intervention services directly from a Municipality and payment from the Municipality for such services rendered must complete and comply with the attached Appendix 1– Payee Provider Agreement/Service Authorizations and Payment. Appendix 1 sets forth the terms and conditions for such authorizations and payment.

Definitions

When used herein, the following terms shall have the following meanings:

"Applied Behavioral Analysis" or "ABA" shall mean the design, implementation, and evaluation of systematic environmental changes to produce socially significant change in human behavior through skill acquisition and the reduction of problematic behavior. ABA includes direct observation and measurement of behavior and the identification of functional relations between behavior and the environment. These include contextual factors such as establishing operations, antecedent stimuli, positive reinforcers, and other consequences that are used to produce the desired behavior change.
"Early Intervention Official" or "EIO" shall mean an appropriate municipal official designated by the chief executive officer of a municipality and an appropriate designee of such official.
"Early Intervention Program" or "EIP" means the program established pursuant to Title II–A of Article 25 of the Public Health Law.
"Family/Caregiver Support Group" is the provision of early intervention services to a group of parents, caregivers (foster parents, day care staff, etc.) and/or siblings of eligible children for the purposes of enhancing their capacity to care for and/or enhance the development of the eligible child and, providing support, education, and guidance to such individuals relative to the child´s unique developmental needs.
"Group Developmental Intervention Visit" shall mean the provision of early intervention services by appropriate qualified personnel to eligible children in a group which may also include children without disabilities, at an approved Provider´s site or in a community–based setting.
"Home and Community Based Individual/Collateral Visits" shall mean the provision by appropriate qualified personnel of services to an eligible child and/or parent or other designated caregiver at the child´s home or any other natural environment in which children under three years of age are typically found (including day care centers other than those located at the same premises as the Provider, and family day care homes).
"Municipality" shall mean a county outside of the City of New York or in the case of a county located within the City of New York. For purposes of this agreement, "Municipality" shall further mean the Municipality in which the Provider renders evaluations, service coordination or early intervention services to children residing in such Municipality.
"Office/Facility–Based Individual/Collateral Visits" shall mean the provision by appropriate qualified personnel of services to an eligible child and/or parent or other designated caregiver at an approved Provider´s site (including day care centers located at the same premises as the Provider).
"Parent–Child Group" is a group comprised of parents or caregivers, children, and a minimum of one appropriate qualified Provider of early intervention services at an early intervention Provider´s site or a community–based site (e.g., day care center, family day care, or other community settings).
"Provider" shall means an agency or individual approved in accordance with 10 NYCRR § 69–4.5 to deliver service coordination, evaluations and screenings and/or services in the EIP.
- "Agency Provider" shall mean an entity which employs qualified personnel as defined in 10 NYCRR §69–4.1(ak), and may contract with individual providers or other agency providers which are approved by the Department, for the provision of early intervention program evaluations and screenings, service coordination, and/or early intervention services.
- "Individual Provider" shall mean a person who holds a state–approved or recognized certificate, license or registration in one of the disciplines set forth in 10 NYCRR § 69–4.1(ak) and who either receive service authorizations for early intervention services from a Municipality and/or are under contract with an agency provider.
"Services" shall mean those early intervention services as defined in 10 NYCRR 69–4.1(l) that the Provider identified in the Provider´s application to the Department as being able to provide, either directly or for Agency Providers through employees and/or contracts with Individual Providers or other Agency Providers.
"Service Coordination Services" means assistance provided by a service coordinator to enable an eligible child and the child´s family to receive the rights, procedural safeguards and services that are authorized to be provided under the EIP.
"State" shall mean the State of New York.

Now, therefore, the Department and Provider agree as follows:

Appendix
The following appendix, when checked, shall be incorporated and made a part of this agreement as if fully set forth herein:

☐ Appendix 1– Payee Provider Agreement/Service Authorizations and Payment
Role of Department, Municipalities and Providers in the Early Intervention Program
Pursuant to Public Health Law (PHL) § 2550, the Department is the lead agency responsible for the administration of the Early Intervention Program in this State. Each individual Municipality and the city of New York is responsible for the local administration of the program, which includes but is not limited to, accepting referrals of children potentially eligible for program services, assigning initial service coordinators, participating in Individualized Family Services Plan (IFSP) meetings, ensuring that early intervention (EI) services contained in an IFSP are appropriately delivered, and reimbursing providers for services not covered by Medicaid or commercial insurance according to rates set by the Department pursuant to regulations. PHL authorizes the Department to contract with a fiscal agent that will handle provider claiming and payment. The Provider hereby understands and agrees that the claims submitted shall be accurate and complete, and shall reflect the actual service rendered. The Provider further understands and agrees that, pursuant to PHL § 2557(3) and (3–a), PHL § 2552(1) and 10 NYCRR § 69–4.12, both the Department and the Municipality are authorized to monitor and audit evaluators, service coordinators and Providers of services within the Municipality. Provider understands and agrees that certain provisions within this Agreement that require notice to the Municipality or includes the Municipality with respect to obligations or requirements, are designed to acknowledge the Municipality´s role in the local administration of the Early Intervention Program and in the oversight of Providers in the delivery and payment for evaluations and services provided to children within such Municipality.
Provider Responsibilities
1. Provider shall comply with all applicable provisions of law, rule and regulation when participating in the Early Intervention Program, including but not limited to PHL §2550 et seq, 10 NYCRR SubPart 69–4, Part C of the Individuals with Disabilities Education Act and its regulations at 34 CFR Part 303, and the Family Educational Rights and Privacy Act (FERPA) and its regulations at 34 CFR Part 99.
2. Agency Provider understands and hereby agrees that it is responsible for and shall ensure that its employees and Individual Providers under contract with such Agency Provider comply with the provisions of applicable law and regulations, and with the terms of this Agreement when delivering evaluations or services on behalf of the Agency Provider.
3. Provider hereby agrees that Provider is able to and shall deliver services in the areas of the State identified in the Provider´s application to the Department. Provider shall only conduct evaluations and deliver the services for which Provider is approved by the Department to deliver.
4. Provider understands and hereby agrees that nothing in this Agreement or Appendix 1 of this Agreement shall be deemed to require or otherwise hold the Department responsible for making payment to the Provider for evaluations or services rendered under the EIP. Provider understands and agrees that reimbursement for evaluations and services are governed by PHL §2557 and §2559. In accordance with those sections, Providers who receive direct service authorizations from a Municipality shall, in the first instance and where applicable, seek reimbursement under a health insurance policy, plan or contract, including under the medical assistance program or the child health insurance program, prior to seeking reimbursement from a Municipality for services rendered to a child who has health insurer or health maintenance organization coverage. Pursuant to PHL §2557, approved costs, other than those reimbursable under a health insurance policy, plan or contract, including under the medical assistance program or the child health insurance program, for evaluations and services shall be a charge upon the Municipality wherein an eligible child resides. Provider shall not seek or be entitled to reimbursement directly from the Department for evaluations or services rendered to eligible children under the EIP.
5. Provider understands and hereby agrees that nothing in this Agreement shall be construed as guaranteeing to Provider a specific number of evaluation assignments or service authorizations. Provider understands and agrees that the Provider may not be assigned any evaluations or provided with any service authorizations in the EIP, and/or that service authorizations may be modified at any time in accordance with PHL, for reasons including but not limited to the eligible child has progressed under the EIP and the IFSP team determines that a service should be reduced or is no longer needed. Provider further understands that payment for evaluations and services under the EIP is subject to funds being appropriated and made available therefor.
Personnel
1. Provider hereby affirms that Provider is capable of delivering services on a twelve–month basis and provides flexibility in hours of service delivery, which includes but is not limited to, rendering services outside of standard business and/or operating hours. This includes but is not limited to service delivery on weekend and evening hours in accordance with eligible children´s IFSPs.
2. Provider shall maintain a statement from a health care Provider which documents that the Provider, and employees and Individual Providers under contract with an Agency Provider, has no diagnosed disorder or condition that would preclude him/her from providing services. Such statement shall be obtained prior to the provision of services and updated on an annual basis thereafter.
3. Provider shall maintain proof from a health care provider that the Provider, and/or employees and Individual Providers under contract with an Agency Provider, meet the following requirements, prior to provision of services:
  - measles, mumps, and rubella titer and/or vaccine; and, annual Mantoux/PPD or chest X–ray with the exception of EI Providers who are also licensed day care providers by the NYC Bureau of Day Care. NYC Bureau of Day Care Providers must demonstrate that upon commencement of work, a record of testing performed for tuberculosis infection, and further testing at any time, if required by the NYC Bureau of Day Care.
  - have the following recommended vaccines or has documented refusal, prior to the provision of EI Provider services: Hepatitis B vaccine; Tetanus immunization within the past 10 years, Diphtheria; Pertussis; Varicella; and, Influenza.
4. Providers shall, in accordance with Social Services Law (SSL) § 424–a, ensure that Statewide Central Register Database Check Form LDSS–3370 is completed and submitted to the State Central register (SCR) for: (i) any person who is being actively considered for employment, and who will have the potential for regular and substantial contact with children who receive early intervention services; and (ii) any prospective Individual Provider providing goods and services who will have the potential for regular and substantial contact with children who receive services. Agency Provider shall complete the SCR database check and must receive an acceptable response from the SCR prior to authorizing or allowing any person or Individual Provider to have any unsupervised contact with a child receiving early intervention services. If any person about whom the Agency Provider has made an inquiry is found to be the subject of an indicated report of child abuse or maltreatment, such Agency Provider must, in accordance with SSL § 424–a, determine, on the basis of information it has available and in accordance with guidelines developed and disseminated by the NYS Office of Children and Family Services for child care services, whether to hire, retain or use the person as an employee, volunteer or contractor or to permit the person providing goods or services to have access to children being served by the Agency Provider. Whenever such person is hired, retained, used or given access to children in the EI program, such Agency Provider must maintain a written record, as part of the application file or employment or other personnel record of such person, of the specific reason(s) why such person was determined to be appropriate and acceptable as an employee, volunteer, contractor or provider of goods or services with access to children being served the Agency Provider.
5. If Agency Provider denies employment or determines not to retain or utilize such person, Agency Provider shall comply with the requirements contained in SSL § 424–a.
6. Provider shall review and become familiar with the Department´s guidance and written policies and procedures for the provision of EI services, including but not limited to guidance regarding referral, eligibility, evaluations, provision of services, record keeping and billing. Agency Providers shall ensure that its employees and Individual Providers under contract with such Agency Providers are familiar with such guidance, policies and procedures.
7. Agency Providers shall only utilize qualified personnel as defined in 10 NYCRR §69–4.1 as appropriate for the provision of authorized services, and shall ensure that such qualified personnel maintain current registration, certification or licensure in the area for which they are providing services on behalf of the agency.
8. Individual Providers shall only render services within the scope of practice for which they are registered, certified or licensed, as appropriate, and within the areas in which the Individual Provider has been trained and educated, and with which he or she is familiar and competent.
9. Agency Providers shall assign a speech language pathologist to provide services to a child when a speech service is authorized in a child´s IFSP; the Agency Provider shall not assign a certified teacher when speech services are authorized in the child´s IFSP and requested by the service coordinator.
10. Provider, employees and independent contractors (including Service Coordinators) utilized by a Provider Agency who deliver services shall demonstrate continued professional development related to their professional field of practice, and on state and municipal policies and procedures of the early intervention program, including participation in Department–sponsored training. Provider shall participate in a minimum of ten clock (10) hours of professional development activities per year. Such professional development activities are not restricted to Department sponsored training and may include other professional activities necessary for licensure and activities identified by the Provider to increase the Provider´s professional skills and knowledge. Activities may include but are not limited to formal continuing education courses/workshops, formal academic study, independent study, mentoring, and in–service training programs. Activities may also include Department sponsored training, Municipal sponsored training, webcasts, and webinars which may be provided particularly during periods of introduction of a new policy and procedure. Provider will maintain documentation of professional development activities and make such documentation available upon request to the Department and/or Municipality.
11. Agency Providers will, before utilizing a student/intern, a physical therapy assistant or an occupational therapy assistant for the provision of EI provider services, notify the Municipality, service coordinator and parent that the Agency Provider intends to have a student/intern, a physical therapy assistant or an occupational therapy assistant provide services under the supervision of a licensed practitioner; provide the Municipality, service coordinator and parent a written plan for how the supervising practitioner will assume professional responsibility for the services provided under his or her direction and how the need for continued services will be monitored; and, have agreement from the Municipality, service coordinator and parent prior to the provision of services by a student/intern, a physical therapy assistant or an occupational therapy assistant.
12. Agency Providers shall maintain, using the Department´s NYEIS database, a contemporaneous list of its employees and Individual Providers under contract with such Agency Provider which reflects the current staff available to provide EI services.
13. Provider shall be familiar with and comply with all applicable Medicaid rules and regulations. Provider shall not engage in any act which constitutes an unacceptable practice under the Medical Assistance Program as enumerated in Title 18 of the New York Code of Rules and Regulations Section 515.2(a) and (b) (1) through (b) (15), (17) and (18). Agency Providers shall not utilize employees or Individual Providers or vendors, who have been excluded from participation in the Medical Assistance Program. Agency Provider shall ensure that they do not employ, or are affiliated with, any individual or agency, which has been excluded from either the Medicare or the Medicaid program. Providers shall routinely screen employees, prospective employees, and contractors both Individuals and other Agency Providers, to determine if they have been excluded or terminated from participation in the Medical Assistance Program.
14. Provider shall provide their own equipment and supplies including toys necessary to conduct their business. Provider understands that it is not the responsibility of the Department or Municipalities to supply such equipment, supplies or toys. Provider shall comply with applicable health and safety standards, including those related to use of toys, equipment and supplies.
15. Provider shall obtain access to the Department´s NYEIS electronic database for at least one person for the purpose of managing EI information necessary to conduct business utilizing NYEIS.
Services
1. Provider shall use informed clinical opinion, observation and ongoing assessment in collaboration with family/caregiver and additional team members to prioritize identified family/caregiver areas of concern. Provider shall be an active participant in the development of integrated family & child focused goals and outcomes for the IFSP. As a licensed and/or certified professional focused on their field of practice, Provider shall encourage families and caregivers to collaboratively identify priorities as they relate to child participation in everyday activities; observe families/caregivers and their children to engage in activities when clinically appropriate; collaboratively documenting child and family strengths, accomplishments, interests and needs which will assist a family to be an informed advocate for their child/children and active member of the IFSP team; and, inform an IFSP team, if the provider is unable to attend an IFSP meeting.
2. Provider shall render services in conformance with the child´s and family´s IFSP, including but not limited to functional outcomes, the duration specified, location and frequency of such service.
3. Provider understands and agrees that the use of aversive intervention in any form is strictly prohibited when providing EIP services. Aversive intervention is defined in 10 NYCRR § 69–4.9 to mean an intervention that is intended to induce extreme or excessive and/or non–therapeutic pain or discomfort to a child for the purpose of modifying or changing a child´s behavior, limiting a child´s free range of movement, or eliminating or reducing maladaptive behaviors, including but not limited to the following: contingent application of noxious, painful, intrusive stimuli or activities; any form of noxious, painful, or intrusive spray (including water or other mists), inhalant, or tastes; contingent food programs that include the denial or delay of the provision of meals or intentionally altering staple food or drink to make it distasteful; movement limitation used as punishment, including but not limited to helmets and mechanical restraint devices; physical restraints; blindfolds; and, white noise helmets and electric shock.
4. Provider shall work collaboratively with the family to identify strategies/activities and the necessary services and supports to achieve IFSP outcomes including but not limited to developing and enhancing the family´s capacity to support their child´s learning and development between visits; building on the interests and strengths of the child and family; and, determining the intensity, and method for each service to be reasonable and not burdensome to the family.
5. Provider shall use a child developmental approach in intervention strategies, incorporating evidence–based child development practices with necessary adaptations to foster and promote age appropriate development.
6. Provider shall use an individualized approach, including consideration and respect for cultural and religious, lifestyle, ethnic, and other individual and family characteristics.
7. Provider shall be an active participant in the development and implementation of a transition plan for a child transitioning from the EIP.
Documentation and Recordkeeping
1. When required by the Department, Provider shall utilize a standardized reporting format when reporting on services delivered in the EIP.
2. Provider shall maintain documentation necessary to support claiming to third party payors (Medicaid and commercial insurers), the Municipality and State. In instances where corrections are made to documentation required to support claiming, the rendering provider shall leave his or her original writing intact, strike through the mistake with a single line, make a legible correction and clearly write his or her initials and date correction was made next to the correction. Provider shall not use white–out in an EI record.
3. Provider shall maintain contemporaneous session notes, utilizing a Department standardized form when required by the Department, following each child and family contact, which shall include the information required in 10 NYCRR 69–4.26(c) including: the recipient´s name, date of service, type of service provided, time the Provider began delivering therapy to child and end time, brief description of the recipient´s progress made during the session as related to the outcome contained in the IFSP, name, title, and signature of the person rendering the service, date the session note was created, and signature of the parent or caregiver which documents that the service was received by the child on the date and during the period of time as recorded by the Provider.
4. Original session notes must be maintained in accordance with the requirements of 10 NYCRR § 69–4.26. In situations where an Individual Provider is rendering services to a child and family under an authorization to such Provider by a Municipality or when the Individual Provider is rendering services as a contractor to an Agency Provider, the Individual Provider shall maintain the original session notes. A Municipality or Agency Provider may request or require submission of copies of such Individual Provider´s session notes. Original EI records generated by qualified personnel who are employees of a Municipality or Agency Provider shall be retained by the respective Municipality or Agency Provider.
5. Provider shall make periodic progress notes summarizing the effectiveness of the service and the progress being made toward outcomes included in the child´s and family´s IFSP. Progress notes shall be made at a minimum frequency of twice during the IFSP yearly cycle – for six month IFSP reviews and for the annual IFSP review. The Department may direct that the progress notes be made in a certain format or manner. Progress notes shall be included in the child´s record and shall be available upon request by the service coordinator, Municipality, or Department.
6. Provider shall maintain records that document the performance of services required to be completed by Provider on behalf of eligible children and their families, including but not limited to: parental consents for provision of evaluations and services; reports, session notes, progress notes, and other documentation related to evaluations or service delivery; a copy of the IFSP; service authorizations; physicians orders and/or prescriptions for services provided and other documents as may be required in regulation.
7. Provider shall maintain accurate and complete records that support claiming for actual services rendered. Provider shall only submit bills for payment that accurately reflects the service provided by qualified personnel authorized to provide the service on the date such service is provided and which shall be consistent with the child´s IFSP.
8. Provider shall retain EI records pertaining to a child and family for a minimum of six years from the date that care, services, or supplies were provided to the child and family. Individual Providers who are licensed, registered, or certified under state education law must retain child and family records for the period of time set forth in the laws and regulation that apply to their profession.
Notifications
1. Provider shall make reasonable efforts to notify the child´s parent/family/caregiver prior to the date and/or within one hour prior to the time on which a EI provider service is to be delivered, of any temporary inability to deliver such service due to circumstances such as illness, emergencies, hazardous weather, or other circumstances which impede the provider´s ability to deliver the service. If circumstances prevent such notification prior to a visit, notification should be provided as soon as possible following the missed visit. Provider shall also make reasonable efforts to notify the child´s parent/family/caregiver if the Provider will be more than fifteen (15) minutes late for a scheduled session, due to uncontrollable circumstances.
2. Provider shall notify the child´s parent and service coordinator at least five (5) business days prior to any scheduled absences due to vacation, professional activities, or other circumstances, including the dates for which the Provider will be unable to deliver services to the child and family in conformance with the IFSP and the date on which services will be resumed by such Provider. Missed visits may be rescheduled and delivered to the child and family by such Provider, as clinically appropriate, agreed upon by the parent and in conformance with the child´s and family´s IFSP.
3. Provider shall notify the child´s service coordinator and early intervention official (EIO) of the intent to permanently terminate the delivery of early intervention program services to a child and the child´s family, for any reason, at least thirty (30) calendar days prior to the date on which the Provider intends to cease providing services.
4. Provider shall notify the child´s service coordinator within twenty–four (24) hours of the child´s absence from more than three (3) consecutive scheduled sessions for the delivery of services, indicating the reason for said absence, if known.
5. Provider shall notify the service coordinator and the Municipality within two (2) business days, when a parent voluntarily withdraws their child from early intervention services with a Provider, for any reason.
6. Provider shall notify the Department, in writing, within five (5) calendar days, in the event Provider becomes a party to any litigation, investigation or transaction that may reasonably be considered to have a material impact on Provider´s ability to perform under this Agreement.
7. Individual Providers shall notify the Department within two (2) business days if their license is suspended, revoked, limited or annulled, regardless of whether the suspension or limitation is stayed.
8. Provider shall notify the Department immediately upon becoming aware that the, Medicare or Medicaid certification of Provider, or any employee or Individual Provider under contract with the Agency Provider is restricted, suspended or temporarily and/or permanently revoked by any regulatory authority.
Mandated Reporting
1. Providers shall report or cause to be reported suspected cases of child abuse and/or maltreatment to the New York State Central Register (SCR) of Child Abuse and Maltreatment whenever they believe that there is reasonable cause to suspect that a child, made known to them in their official capacity as a Provider under the EIP, is or has been abused or maltreated.
2. Provider shall develop and maintain policies and procedures regarding the reporting of suspected child abuse and/or maltreatment. Agency Providers shall ensure that its employees and Individual Providers under contract with such Agency Provider are aware of the Agency Provider´s policies and procedures in this regard.
Confidentiality
1. Provider shall preserve the confidentiality of all electronic and/or hard–copy data and information, both historical and current data, that is shared, received, collected, or obtained in relation to services provided in the EIP, in accordance with applicable law and regulations, including but not limited to FERPA and 10 NYCRR § 69–4.17.
2. Provider shall keep child records secure, whether records are stored in a business location, an Individual Provider´s home or at a secure location outside the Provider´s home. Provider shall have a written policy on confidentiality and meet all confidentiality requirements of the EIP, including physical security. – 7 –
3. Provider shall prevent the disclosure, re–disclosure or release of such data or information, except as expressly authorized by law. Provider shall not use such data or information for personal benefit.
4. Provider agrees to develop and maintain specific procedures ensuring the protection of health history information related to an individual who has been diagnosed as having AIDS or HIV–related illness or HIV infection or laboratory tests performed on an individual for HIV–related illness.
5. Agency Provider agrees to comply with the confidentiality and disclosure requirements set forth in and in Part 403 of New York State Social Service Law and Section 2782 of Public Health Law, and ensure that staff, to whom confidential HIV–related information is disclosed as a necessity for providing services, are fully informed of the penalties and fines for re–disclosure in violation of State law and regulations.
6. The Provider fully agrees that any disclosure of confidential HIV–related information shall be accompanied by a written statement as follows:
  
  This information has been disclosed to you from confidential records, which are protected by State law. State law prohibits you from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law. Any unauthorized further disclosure in violation of State law may result in a fine or jail sentence or both. A general authorization for the release of medical or other information is NOT sufficient authorization for further disclosure.
Marketing
1. Provider shall comply with the provisions of 10 NYCRR § 69–4.5(e).
2. Provider shall not represent themselves as, or claim to be, an officer or employee of the State or Municipality by reason of this Agreement.
3. Provider shall ensure that marketing and advertising materials adhere to the Department´s Marketing Standards for Early Intervention Service Providers and adequately inform parents or guardians of children less than three years of age who are suspected of having a disability or are at risk of disability about the EIP.
Auditing, Monitoring, Due Process
1. Provider shall cooperate with any announced or unannounced fiscal audit, programmatic monitoring and/or quality improvement monitoring by the Department, Municipality or its respective designee. Provider shall maintain and make available to the Department and Municipality upon request, complete financial records and clinical documentation related to the provision of services to permit a full fiscal audit by appropriate State and municipal authorities.
2. Provider shall make available such records or documents that are requested on the date and time of the visit, and shall provide access to the facility for facility based Providers.
3. Provider shall render diligently to the Department and the Municipality any and all cooperation, without additional compensation, that may be required as part of an investigation, mediation, or hearing.
4. Provider shall demonstrate full and faithful cooperation with any investigation, audit or inquiry conducted by the Department, Municipality or State or Federal governmental agency or authority that is empowered directly or by designation to compel attendance of witnesses and to examine witnesses under oath, or conducted by a governmental agency that is a party in interest to the transaction, that is subject of the investigation, audit or inquiry.
5. Provider shall render diligently to the Municipality and Department any and all cooperation, without additional compensation, that may be required to defend the Municipality and/or Department against any claims, demand, or action that pertain to Provider that may be brought against the Municipality and/or the Department in connection with services rendered by or on behalf of Provider to children under the Early Intervention Program and/or the terms and provisions of this Agreement.
6. Provider shall implement to the satisfaction of the Department, corrective actions deemed necessary by the Department or its designee to bring the Provider into compliance with applicable State and Federal statutes and regulations governing the EIP. Provider shall further implement, to the satisfaction of the Municipality, any corrective actions as may be required by Municipality after an audit or monitoring of the Provider by the Municipality in accordance with PHL § 2557(3–a), PHL § 2552(1) and 10 NYCRR § 69–4.12.
7. Provider understands and hereby agrees that payment by the Municipality may be withheld or suspended if upon audit or monitoring by the Department or Municipality it is found that the Provider, and/or employees or Individual Providers under contract with an Agency Provider, did not provide the services billed for, the services were not provided in conformance with a child´s IFSP, the rendering provider was not qualified by licensure, certification or registration to deliver the services, and/or the services were not provided in conformance with law or regulation or this Agreement.
EI Model Specific Responsibilities
1. Service Coordination
  - A1. Provider, and employees and Individual Providers under contract with an Agency Provider, who deliver service coordination services, shall, in accordance with 10 NYCRR §§ 69–4.4 and 69–4.5(xi) demonstrate continued professional development on state and local policies and procedures of the EIP, including participation in Department–sponsored training. Provider shall maintain documentation of continuing education/training and make such documentation available upon request to the Department and Municipality.
  - A2. Provider shall ensure that they, their employees and independent contractors utilized by the Provider Agency demonstrate participation in on–going training including but not limited to introductory service coordination, advanced service coordination, evaluation, and IFSP training sponsored or approved by the Department of Health, when Provider is approved for service coordination services.
  - A3. Provider, and employees and Individual Providers utilized by an Agency Provider who deliver service coordination services on behalf of the Agency Provider shall complete introductory service coordination training sponsored or approved by the Department of Health prior to rendering service coordination services and participate in a minimum of one (1) professional development activity totaling a minimum of 1 1/2 clock hours directly related to service coordination per calendar year, such activity is not limited to Department sponsored training but can include other professional development activities which focus on enhancing skills necessary for service coordinators to increase their competency to provide service coordination activities.
  - A4. Provider shall render all service coordination activities as set forth in applicable law and regulations and as specified in the child´s IFSP.
  - A5. Provider of initial and/or ongoing service coordination services shall document all activities (billable and non–billable) related to the performance of their duties which includes the following information: recipient´s name; date of service; a description of the specific service coordination activity performed; name, date of contact, and purpose of contact for providers or others contacted on behalf of the child and family as necessary to implement the IFSP; start and end time for each contact; and, name, title and signature of the service coordinator, as applicable. The Department may require that the Provider document such activities using a standard form or format.
  - A6. Provider shall provide Service Coordination as authorized by the Municipality when authorized for initial service coordination, and when authorized for on–going service coordination for a child/family, up to the limit of units of service coordination prescribed in the IFSP and indicated on the service authorization. Provider shall provide additional units of service only if authorized in accordance with a fully executed amendment to the IFSP, which shall include signatures of the Parent (s) and EIO/designee and IFSP team members.
  - A7. Provider shall prepare and submit reports and/or data regarding Service Coordination activities as requested by the Department or Municipality in a manner and format as may be requested by the Department or Municipality.
  - A8. Provider shall be reasonably accessible to the child´s evaluator, other Providers of EI services, the Department and the Municipality during standard business hours.
  - A9. The Provider shall be reasonably available to the parent in a manner that does not limit service access to daytime and/or weekday hours and does not limit access to a specific location. The Provider shall ensure that accessibility for service coordination are available to families in non– traditional schedules and through a variety of methods and locations. Provider shall be responsible for informing families of changes to their contact number, email address, and the specific times and places of their accessibility.
  - A10. Provider shall communicate with the family about the purpose of Early Intervention, provide all information to the family in the family´s dominant language or other mode of communication unless clearly not feasible to do so, and shall ensure that the family has received or has access to the current version of The Early Intervention Program: A Parent´s Guide, the parent´s handbook that provides information about the program upon referral to the EI Program.
  - A11. Provider shall describe the rationale for services in natural environments. Provider shall describe each step of the IFSP process, including its purpose, and what service delivery might look like.
  - A12. Provider shall collaboratively balance listening to the family with sharing information and shall use open–ended questions that encourage the family to share their thoughts and concerns. Provider shall discover family preferences for sharing and receiving information as well as the family´s teaching and learning strategies they prefer to use with their child.
  - A13. Provider shall review with the EI family the EIP procedural safeguards/due process rights upon initial contact with the family and whenever the family may disagree with an eligibility decision or with the early intervention official/designee decision regarding services for their child/family.
  - A14. Provider shall assist families to obtain the services and/or assistance they need.
  - A15. Provider shall inform the family that services must be at no cost to families, use of Medicaid and/or third party insurance for payment of services is required under the EIP, that any deductible or co– payments is not the responsibility of the family; the use of third party insurance for payment of early intervention services will not be applied against lifetime or annual limits specified in their insurance policy, if such policy is subject to New York State law and regulation; and, that the Municipality/Department/service coordinator will not obtain payment from their insurer, if such policy is not subject to New York State law and regulation and if the insurer is therefore not prohibited from and will apply payment for early intervention services to the annual and lifetime limits specified in their insurance policy. Provider shall collect, from the family, information on any insurance policy, plan or contract under which an eligible child has coverage.
  - A16. Provider shall review all options for evaluation and screening with the family from the list of approved evaluators including location, types of evaluations performed, and settings for evaluations (e.g., home vs. at the evaluation agency). Upon selection of an evaluator by the family, the Provider shall ascertain from the family any needs the family may have in accessing the evaluation. Provider shall at the family´s request, assist the family in arranging of the evaluation after the family selects from the list of approved evaluators.
  - A17. Provider shall contact the family to ensure that the family has received information concerning alternative approved evaluators and ascertain from the family any needs the family may have in accessing the evaluation, if the family has accessed an approved evaluator prior to contact by the initial service coordinator.
  - A18. Provider, upon receipt of the results of the evaluation, may with parental consent and the approval of the early intervention official, require additional diagnostic information regarding the condition of the child, provided that such information is not unnecessarily duplicative or invasive to the child according to guidelines of the Department of Health. One such example is that such information may assist the IFSP team to determine the appropriate type, location, frequency or duration of the EI provider service.
  - A19. Provider shall prior to obtaining written parental consent for additional diagnostic information, provide the family with a written explanation which shall include: diagnostic information requested; reasons for obtaining the information, and use of the information; location of diagnostic testing; source of payment and that no costs shall be incurred by the parent; a statement that the information shall not be used to refute eligibility; and, a statement that the meeting to formulate the Individualized Family Service Plan shall be held within the 45 day time limit.
  - A20. The Provider shall, with parent consent, notify the Office for People with Developmental Disabilities´ regional developmental disabilities services office of the potential eligibility of a child for programs or services available under that Office, if the Provider, in consultation with the evaluator, identifies the child as potentially eligible for programs or services offered by or under such office.
  - A21. Provider shall, upon the determination of a child as ineligible for EIP services, inform the family of the right to due process procedures as set forth in 10 NYCRR § 69–4.17 and shall inform the family of other services which the family may choose to access and for which the child may be eligible and offer assistance with appropriate referrals.
  - A22. Provider shall collect from the family a written referral from a primary care Provider as documentation, for eligible children, of the medical necessity of EIP services in order to support private insurance claiming.
  - A23. Provider shall assist the family in preparing for the meeting to develop the IFSP, including facilitating their understanding of the child´s multidisciplinary evaluation and identifying their resources, priorities, and concerns related to their child´s development.
  - A24. Provider shall inform the family of the opportunity to select an ongoing service coordinator, who may be different from the initial service coordinator, at the Individualized Family Service Plan meeting or at any other time after the formulation of the IFSP.
  - A25. Provider shall ensure that the IFSP, including any amendments thereto, is implemented in a timely manner within thirty (30) days of parent consent to the IFSP, or if the projected date for the initiation of a service is greater than thirty (30) days of parent consent to the IFSP, not later than thirty (30) calendar days after the projected date for initiation of the service.
  - A26. Provider shall in consultation with the service Provider and the family/caregiver continuously seek the appropriate services and situations necessary to benefit the development of the child for the duration of the child´s EIP eligibility, including providing appropriate referrals for families to access social and mental health services.
  - A27. When notified by a Provider or by otherwise becoming aware of a child´s absence from more than three (3) scheduled sessions for the delivery of services, Provider shall contact the child´s parent/family to ascertain the reason for any absences and immediately notify the EIO regarding the absences, reason for such absences and whether there is a need to modify an existing IFSP.
  - A28. Provider shall early in the relationship with the family, have conversations about what they want for their child´s future once they transition from the EIP.
  - A29. Provider shall identify transition issues and discuss steps to prepare the family for choices/options at different transition points and to prepare the child for participating in the new setting when transition occurs. Provider shall ensure that the family understands the timeframe for transition from the EIP and when transition planning should occur.
  - A30. Provider shall, together with the IFSP team, develop a transition plan as part of the IFSP process which includes the outcomes and activities to prepare the child and family for success after early intervention.
  - A31. When applicable, Provider shall notify the local Committee on Preschool Special Education of a child´s potential transition to CPSE services utilizing Department–standardized forms, procedures, and timelines in accordance with applicable law and regulations.
  - A32. Provider understands and agrees that, in accordance with PHL § 2552, a Municipality may request that the parent/family select a new service coordinator or require that the service coordinator select a new Provider of services if the Municipality finds that the service coordinator or Provider, as applicable, has not been performing his or her responsibilities as required or that services have not been provided in accordance with the child´s IFSP.
2. Evaluations & Screenings
  - B1. Provider shall only provide evaluation and screening services as authorized in accordance with their licensure, registration or certification. Agency Providers shall only use qualified personnel who are licensed, certified or registered in the area for which they are providing evaluation services for the provision of core/multidisciplinary evaluations and/or supplemental evaluations
  - B2. Provider shall provide evaluations in accordance with a service authorization issued by the Municipality or service coordinator. If the parent selects an approved Provider to conduct the evaluation prior to the designation of an initial service coordinator, the Provider shall immediately notify the EIO of such selection and shall begin the evaluation no sooner than four (4) business days of the EIO´s receipt of written notice from the Provider. The Provider shall obtain parental consent to conduct the evaluation prior to the initiation of the evaluation.
  - B3. Provider shall when conducting a multidisciplinary evaluation include qualified personnel who have sufficient expertise in child development, and include at least one qualified personnel in the area of the child´s suspected delay or disability. The primary area of concern must be included as part of the core evaluation. No evaluation may be performed by telephone, in whole or in part.
  - B4. Provider shall when conducting a family assessment include qualified personnel who are trained in the use of professionally accepted methods and procedures to assist the family in identifying their concerns, priorities, and resources related to the development of their child.
  - B5. Provider shall ensure that they and, if applicable, their employees who provide Evaluation & Screening services complete continuing professional and clinical education relevant to early intervention services, and in–service training sponsored by the Department regarding evaluation and eligibility, within six (6) months of becoming an employee of the Agency Provider or within six (6) months of the start date of the Agreement, whichever is later. Provider or employees of an Agency Provider who render evaluations and screenings shall also participate in a minimum of one (1) professional development activity totaling a minimum of 1 1/2 clock hours per year related to the provision of evaluation & assessments to children under the age of 5 years old, such activity is not limited to Department sponsored training but can include other professional development activities which focus on enhancing skills necessary for evaluators to increase their competency to provide evaluation activities. Provider shall have the training and competency to administer a particular evaluation tool prior to conducting an EI evaluation utilizing such tool. Agency Providers shall ensure that its employees who conduct evaluations have the training and competency to administer a particular evaluation tool prior to conduct an unsupervised evaluation.
  - B6. Provider shall ensure that they and, if applicable, all employees and Individual Providers under contract to provide evaluations for an Agency Provider, have access to the Department´s guidance regarding evaluations and eligibility criteria for the early intervention program, prior to conducting an evaluation or screening and that it is implemented appropriately.
  - B7. Provider shall have availability and competency to screen, evaluate, and assess infant and toddler development using appropriate methods and procedures, both formal and informal.
  - B8. Provider shall utilize evaluation and assessment procedures that are responsive to the cultural, ethnic, religious and linguistic background of the family. Tests and other evaluation materials and procedures shall be administered in the dominant language or other mode of communication of the child, unless it is clearly not feasible to do so. If such an evaluation is not possible, Provider should not accept the evaluation assignment or must document the attempts to locate a bilingual evaluator and notify the service coordinator of their inability to provide the evaluation in the dominant language or other mode of communication of the child and receive further direction from the service coordinator before proceeding with the evaluation. The service coordinator may, after discussion with and consent by the parent, request that the evaluation be reassigned to another Provider or Provider Agency.
  - B9. Agency providers shall only use qualified personnel who are licensed, certified or registered in the area for which they are providing evaluation services for the provision of core/multidisciplinary evaluations and/or supplemental evaluations.
  - B10. Provider shall adhere to recognized standards of practice for their respective disciplines when conducting evaluations and utilizing and scoring standardized assessment instruments.
  - B11. Provider shall, when conducting a multidisciplinary evaluation include the core components of a developmental assessment of all domains (physical development, cognitive development, communication development, social or emotional development, and adaptive development); a review of pertinent records, parent interview, and, at the option of the family, a family assessment.
  - B12. Provider shall use the most recent edition of a standardized test instrument as soon as practicable (e.g., when the standardized instrument has become widely available, including the availability of training, if required by test developers) when conducting evaluations for the purpose of determining a child´s initial or ongoing eligibility for the EIP. Standardized test instruments must be administered, scored and interpreted according to the tool´s manual.
  - B13. Provider understands that no single procedure or instrument may be used as the sole criterion or indicator of eligibility. Provider shall utilize information from a variety of appropriate sources, including but not limited to standardized instruments and procedures, when appropriate or possible; observations of the child; parent interviews; informed clinical opinion; and, any other sources of information about the child´s developmental status available to the team conducting the child´s evaluation.
  - B14. Provider shall consider the parent´s input regarding the preferred natural environment/setting for the evaluation and should conduct an evaluation in a setting conducive to ensuring accurate results. After the evaluation, the family should be asked whether they believe their child´s response was optimal, and the family´s response shall be included in the evaluation summary and report.
  - B15. Provider shall immediately notify the Parent, the Service Coordinator and EIO/M, prior to initiation of the Evaluation if the Provider reasonably believes that the Provider cannot provide an evaluation within a sufficient time frame so that it can be accomplished within forty–five (45) days necessary to schedule an IFSP (due to workload or scheduling issues).
  - B16. Provider shall provide the family a single point of contact and phone number for the evaluation process.
  - B17. Provider shall describe to the family each step of the evaluation process, including its purpose, and what the evaluation might look like, including process, rules and procedures that Providers must follow.
  - B18. Provider shall discuss how information gathered from the family is used in planning and conducting the evaluation. Provider shall help the family decide how they want to participate in their child´s evaluation. The child´s parent shall have the opportunity to be present and participate in the performance of evaluation and assessments, unless the parent´s circumstances prevent the parent´s presence.
  - B19. Provider shall provide evaluation results in layman´s terms/user friendly language in a manner which is understandable to family and caregivers. Provider shall discuss screening, evaluation, and assessment information with families in understandable language and in the context of the child´s strengths. Provider shall ensure that parents are afforded the opportunity to discuss the evaluation results with evaluators, including any concerns they have with the evaluation process.
  - B20. Provider shall ensure that when conducting a multidisciplinary evaluation, the Evaluator prepares an evaluation report and written summary and submits the summary, and upon request the report, to the following individuals within sufficient time to ensure completion of the IFSP within forty–five (45) days of a child´s referral to the EIP: the child´s parent(s); the EIO; and, the initial service coordinator. Provider shall ensure that the multidisciplinary report is coordinated by a qualified personnel who conducted the child´s evaluation.
  - B21. Provider shall ensure that Provider creates one integrated multidisciplinary report according to a state–standardized form and that the evaluation report and summary include the names, titles, and qualifications of the persons performing the evaluation and assessment; a description of the assessment process; the child´s responses to the procedures and instruments used as part of the evaluation process, the family´s belief about whether the responses were optimal; the developmental status of the child in each of the five developmental domains, including the unique strengths and needs in each area; documentation of how clinical opinion was used by the persons performing the evaluation and assessing the child´s developmental status and potential eligibility for the EIP; and, measures and/or scores that were used, if any; and, an explanation of these measures or scores. The evaluation report shall also include diagnostic information and ICD–9 codes related to the child´s eligibility, where appropriate.
  - B22. Provider shall ensure that when a diagnosis is made during the course of the evaluation, one or more persons who conducted the evaluation are qualified under the NYS Education Law to render the diagnosis. A diagnosis shall not be rendered by an evaluation team member unless they are qualified by their profession to render such diagnosis.
  - B23. Provider shall fully document the basis for Provider´s eligibility determination and provide such information and documentation that may be requested by the Municipality or the Department within the timeframes specified.
  - B24. Provider shall ensure that if the results of the multidisciplinary evaluation indicate the child is not eligible for the EIP, the team´s evaluation report will clearly document reasons why the child is not eligible. If a child is not eligible for the EIP but has a developmental delay and the evaluation team believes the child should receive services or supports outside of the EIP, the evaluation team should inform the family of options for services and community resources that will promote the child´s development
  - B25. Provider shall submit any additional documentation or explanation requested by the Municipality, service coordinator or Department with regard to any evaluation, within five (5) business days of the request.
  - B26. Provider understands and agrees that all evaluations must be completed in accordance with applicable law and regulations in order to receive payment for the same.
  - B27. Provider shall participate in IFSP meetings in accordance with the requirements of 10 NYCRR § 69–4.11.
  - B28. Provider understands and agrees that if the EIO determines that the Provider has not complied with PHL and/or regulations pertaining to an evaluation, the EIO may require that the Provider immediately submit additional documentation to support the eligibility determination and no later than five (5) business days, or if the documentation provided continues to be inconsistent with PHL or regulations, the EIO can require that the parent select another Provider to conduct a multidisciplinary evaluation to determine whether the child meets eligibility for EIP services.
3. Home/Community–Based and Office/Facility–Based Individual/Collateral Visits
  - C1. Provider shall provide home/community–based individual/collateral services in accordance with a service authorization issued by the Municipality or service coordinator.
  - C2. Provider shall assist families in learning ways that the family can report more effectively on their observations and understanding (assessment) of their child´s skills, behaviors and interests. Provider shall document a family´s observations and assessments into the child´s session notes. Family observations and assessments should be encouraged but not required.
  - C3. Provider shall apply knowledge of current research and evidenced based practices to the development and implementation of strategies, therapy and interventions with the child and family.
  - C4. Provider shall work collaboratively with family/caregivers to seek opportunities to adapt learning experiences and therapeutic strategies to reflect individual characteristics of the child and family, and to identify and implement, as appropriate, strategies that enhance and promote the child´s participation in natural learning opportunities across both child and family routines and community settings.
  - C5. Provider and family/caregivers shall collaboratively identify toys, materials, interactions and locations that are available, of interest to, and motivating for the child and family.
  - C6. Provider and family/caregivers shall collaboratively identify and incorporate family identified resources, concerns and priorities which shall result in individualized strategies promoting the outcomes identified by the family, therapeutic outcomes and outcomes identified in an IFSP. Provider shall be aware of and acknowledge new family concerns or interests.
  - C7. Provider shall assist the family in learning how to communicate with their child.
4. Group Developmental Intervention
  - D1. Provider shall provide group developmental intervention services in accordance with a service authorization issued by the Municipality or service coordinator.
  - D2. Provider shall only utilize qualified personnel as defined by 10 NYCRR § 69–4.1(ak) when assigning a substitute in situations where the usual group leader is absent.
  - D3. Provider shall provide EI services in a safe, developmentally appropriate environment which has adequate space for the group–size, a physical environment and facilities conducive to learning and reflective of the different stages of development of each child. Providers should incorporate, when possible, Universal Design for Learning principles into the creation of learning environments that support all children, including children with disabilities, when designing a learning environment. Provider agrees that it shall only provide Group developmental services in a location that has been included in Provider´s application to the Department.
  - D4. Provider shall support a child´s positive behavior through well–organized classrooms, consistent schedules, well–designed learning areas, established routines, and sensitive and appropriate guidance strategies.
  - D5. Provider shall engage in ongoing adaptations of the environment to meet the needs of individual children, including varying teaching strategies which can influence a child´s ability to participate.
  - D6. Provider shall have clear curricular goals and learning outcomes and where appropriate individualized learning objectives for children and modification of instructional materials as indicated on the child´s IFSP.
  - D7. Provider shall promote supportive interventions within the classroom which minimize the need for a child to be pulled out of the group for an individualized intervention.
  - D8. Provider shall foster a collaborative partnership with all persons involved with the child including the child´s family, caregivers and other Providers and will create an individualized learning experience reflective of the individual child´s social and cultural experience, child´s interests, abilities, and developmental progress. Provider shall inform the child´s family on a regular basis about their child´s progress and experience in the group developmental setting.
5. Parent–Child Groups and Family/Caregiver Support Groups
  - E1. Provider shall provide parent–child groups and family/caregiver support group services in accordance with a service authorization issued by the Municipality or service coordinator.
  - E2. Provider shall assist parents to understand their child´s needs and identify community resources to meet family and child needs and to understand the emotional impact of having a child with disabilities.
  - E3. Provider shall assist the family to learn multiple strategies for communicating with their child.
  - E4. Provider shall assist the family to be confident in their parental skills and in their ability to care for a child with disabilities.
  - E5. Provider shall assist the family to communicate with the team who works with his/her child and family and to develop skills as an advocate for the child.
  - E6. Provider shall assist the family to do things with and for their child that will help enhance their child´s development.
  - E7. Provider shall assist the family to learn how to communicate with their child.
  - E8. Provider shall assist the family to learn how to understand and manage their child´s behavior.
  - E9. Provider shall assist the family to develop skills to cope with stressful situations.
  - E10. Provider shall assist the family to enhance their own ability to modify family routines, such as mealtimes or bedtime, bathing and dressing to accommodate the family needs as well as the developmental and emotional needs of their child and to improve the family´s quality of life.
6. Agency Providers Using Applied Behavior Analysis (ABA) Aides in the Delivery of ABA Early Intervention Provider Services
  - F1. Agency Provider shall only utilize ABA aides to assist in the delivery of ABA services if approved to do so by the Department.
  - F2. Agency Provider shall provide ABA services utilizing ABA aides in accordance with 10 NYCRR § 69–4.25 and a service authorization issued by the Municipality. Agency Provider shall ensure that its employees and Individual Providers under contract with Agency Provider that provide services to an eligible child receiving ABA services from the Agency Provider comply with the requirements contained in 10 NYCRR §69–4.25.
  - F3. Agency Provider shall assist the family to understand ABA therapy, the role of an ABA supervisor and an ABA aide, as well as parental involvement and the role of other team members who may be providing EI services to his/her child.
  - F4. Agency Provider shall ensure that individuals employed as ABA aides meet the following minimum qualifications as per Department regulation: a high school diploma or its equivalent; and, two years of full–time direct, supervised work experience providing services to children with disabilities under the age of five years; or, current matriculation in a degree program in psychology, early childhood development, early childhood education, speech language pathology, special or elementary education, or in a degree program necessary for a license, registration, or certification in a profession designated as qualified personnel; or, an Associate´s or higher level degree in psychology, early childhood development, early childhood education, speech language pathology, special or elementary education, or in a discipline necessary for license, registration, or certification in a profession designated as qualified personnel, or certification as a teaching assistant or, board–certification as a behavior analyst or assistant behavior analyst credentialed by the Behavior Analyst Certification Board, Inc., who are not otherwise licensed, registered, or certified by the New York State Education Department in a discipline included in the list of qualified personnel and supervisors and qualified personnel utilized in the provision of ABA to a child meet the training, experience and supervision requirements set forth in 10 NYCRR 69–4.25, as applicable.
  - F5. Agency Provider shall coordinate all services included in a child´s and family´s IFSP, for each child who is receiving ABA services from the Agency Provider. The Agency Provider shall implement a collaborative team in the approach to delivery of services among all qualified personnel and ABA aides, and require that all personnel delivering services to the child and family participate in team meetings.
  - F6. Agency Provider shall assign each child to a team responsible for the implementation of the child´s and family´s ABA intervention program and other services authorized in the IFSP. The team shall consist of a supervisor, ABA aides, and where applicable, other qualified personnel to deliver early intervention services identified in the child´s and family´s IFSP.
  - F7. Agency Provider, employees and independent contractors utilized by a Provider agency who deliver services shall not delegate the performance of any service or intervention included in the scope of practice of any profession licensed, certified, or registered by the State to ABA aides. ABA aides shall be strictly prohibited from providing services that are within the scope of any profession licensed, certified, or registered by the State. Agency Provider, employees and Individual Providers under contract with Agency Provider who deliver ABA services shall use systematic measurement and data collection to monitor and document child progress, and where indicated, modify individual child ABA intervention strategies as needed to promote progress towards goals and generalization of learning.
  - F8. Agency Provider shall maintain and implement written policies and procedures for the delivery of ABA services which are in conformance with nationally recognized, evidence–based practices for the delivery of such services. Such written policies and procedures shall be: reviewed at least annually by the agency and updated as necessary to maintain conformance with evidence–based practices for delivery of ABA services; and, made available for review for monitoring purposes and upon request by the Department and/or its agent and the Municipality.
  - F9. Agency Provider shall maintain and implement a plan to ensure the initial and ongoing training of supervisory personnel and ABA aides in content areas identified by the Department or national and state professional associations for behavior analysis as necessary for the effective delivery of behavior interventions using applied behavior analysis. Such plan must include required staff participation in training sponsored by the Department.
  - F10. Agency Provider shall employ qualified professionals from the following professions to supervise and oversee individual child ABA services using ABA aides: psychiatrist; psychologist; licensed clinical social worker; special education teachers and teachers of students with disabilities, birth to grade two; and, speech–language pathologists who are also board–certified behavior analysts credentialed by the Behavior Analyst Certification Board. Agency Provider supervisors shall be responsible for: developing individual child ABA plans in collaboration with the child´s family and, as appropriate, qualified personnel and ABA aides; directing the implementation of individual child ABA plans and the ongoing monitoring, systematic measurement, data collection, and documentation of child progress; modifying individual child ABA services as necessary to promote progress towards goals, generalization of learning, and where applicable, transitioning of the child from receiving services in home– and facility–based settings to receiving services and participating in other community settings.
  - F11. Agency Provider supervisors shall provide assistance, training, and support as needed by parents/caregivers to assist them in follow–through specified in the child´s ABA plan and to enhance child development, behavior, and functioning.
  - F12. Agency Provider supervisors shall supervise ABA aides. Such supervision shall include: a minimum of six hours per month in the first three months of employment of an ABA aide, and a minimum of four hours per month thereafter, of direct on–site observation of each ABA aide assigned to the child; and, a minimum of two hours per month of indirect supervision of ABA aides assigned to the child, in a group or individual format, including: weekly review and signed approval of the child´s record, progress notes and data, correspondence, and evaluation of written reports; participation in telephone conferences with the behavior aide and parent; ensuring proper documentation of the intervention provided and child´s response; ensuring modifications in the child´s plan are followed by the ABA aide; and, other supervision and support as needed by the ABA aide to successfully implement the child´s ABA plan.
  - F13. Agency Provider supervisors shall convene a minimum of two team meetings per month with all qualified personnel who are delivering services to the child and ABA aides assigned to the child to review child progress, identify problems or concerns, and modify intervention strategies as necessary to enhance child development, behavior, and functioning.
  - F14. Provider Agency shall ensure that prior to the provision of services to any child without direct, on– site supervision, ABA aides shall complete a child abuse and neglect identification and reporting workshop; complete a minimum of twenty (20) clock hours of training or in–service in behavior interventions using ABA techniques within the past five years, including at a minimum, basic principles of behavior analysis and the application of these principles in behavior intervention, collection of data as needed for monitoring child progress, ethical issues related to the delivery of applied behavior interventions and, an understanding of autism and pervasive developmental disorder.
  - F15. Agency Provider shall ensure that ABA aides complete a minimum of ten (10) clock hours of additional training or in–service annually in topics pertaining to ABA services, and autism spectrum disorders or other disabilities for whom such interventions have been proven effective or matriculation in a degree program such as psychology, early childhood development, early childhood education, speech language pathology, special or elementary education, or in a degree program necessary for a license, registration, or certification in a profession designated as EI qualified personnel.
  - F16. Agency Provider shall ensure that under the supervision and direction of a supervisor in accordance with this section, ABA aides shall assist the supervisor and qualified personnel with the implementation of individual child ABA plans; assist in the recording and collection of data needed to monitor child progress; participate in required team meetings, and complete any other activities as directed by his or her supervisor and as necessary to assist in the implementation of individual child ABA plan.
  - F17. Agency Provider shall ensure that employees and independent contractors utilized by a provider agency providing ABA services using ABA aides and/or other early intervention services included in a child´s and family´s IFSP participate in the ongoing, systematic measurement, data collection, and documentation of the child´s progress, conduct data reviews on an ongoing basis to identify modifications that may be needed to individual child ABA plans as appropriate, provide direction and support to ABA aides as needed and appropriate to assist such aides with the implementation of individual child ABA plans, train and support the child´s parent and/or caregivers to assist the parent and/or caregiver in follow–through with the child; and, collaborate with other qualified personnel and ABA aides in implementing individual child ABA plans and IFSPs, including participating in team meetings convened by supervisors of ABA plans.
Additional Provider Responsibilities
1. Provider understands and agrees that nothing herein shall be deemed to create an "employee" and "employer" relationship between the Department and the Provider, or between the Municipality and the Provider. The relationship of the Provider to the Department or Municipality shall be that of an Independent Contractor for whom no federal or state income tax will be deducted by the Municipality in payment for services provided, and for whom no retirement benefits, workers´ compensation protection, survivor benefit insurance, group life insurance, vacation and sick leave, liability protection, and similar benefits available to the State or Municipal employees will accrue.
2. Provider shall be responsible for the services for which Provider is approved to deliver and, with respect to Agency Providers, shall only utilize employees and/or Individual Providers and/or another Agency Provider when approved by the Department as an Agency Provider. Agency Provider agrees that when utilizing Individual Providers or another Agency Provider to deliver authorized services, the Agency Provider shall remain responsible for the services for which it is authorized to deliver that were rendered by the Individual Provider and/or the other Agency Provider, including but not limited to all claims for payment related to such services, and in ensuring that the Individual Provider and/or the other Agency Provider complied with all applicable rules and regulations in relation to such services.
3. Agency Provider shall be responsible for the acts and omissions of Individual Providers and/or other Provider Agencies utilized by the Provider Agency for the provision of services as it is for the acts and omissions of persons directly employed by it.
4. Provider shall maintain continued compliance with all applicable provisions of the Federal and State Labor Standards.
5. Provider shall maintain continued compliance with all applicable provisions of the Federal Internal Revenue Code, 20 NYCRR–Taxation and Finance, and all rules promulgated there under, including withholding provisions and timely deposits of employee taxes and unemployment insurance taxes, as applicable.
6. Provider shall operate and provide services in compliance with the provisions of the Civil Rights Act of 1964, as amended; with 44 CFR Part 7, entitled "Nondiscrimination in Federally Administered Programs"; and with 45 CFR Parts 84 and 85, entitled "Non–Discrimination on the Basis of Handicap in Program Activities Receiving or Benefiting from Federal Financial Assistance".
7. Provider shall operate, hire, subcontract and provide services without regard to race, creed, color, national origin, sex, age, disability, sexual orientation, genetic predisposition or carrier status or marital status.
8. Provider shall not have religious worship, instruction, or proselytizing as part of or in connection with the provision of early intervention Provider services, nor shall any of the funds provided under this Agreement be used for such purposes.
9. Provider shall operate, hire and subcontract in compliance with the provisions of Article 15 of the New York State Executive Law (also known as the Human Rights Law) and all other State and Federal statutory and constitutional non–discrimination provisions.
10. Agency Provider shall, in the event that the Agency Provider files for bankruptcy or reorganization under Chapter seven or Chapter Eleven of the United States Bankruptcy Code, disclose such action to the Department within (7) seven days of filing. This Agreement shall not be assigned by the Provider or its right, title or interest therein assigned, transferred, conveyed, sublet or otherwise disposed of and attempts to do so are null and void.
11. Indemnification:
  1. Provider shall be solely responsible and answerable in damages for any and all accidents and/or injuries to persons (including death) or property arising out of or related to the services to be rendered by the Provider or its employees or Individual Providers under contract, pursuant to this AGREEMENT. The Provider shall indemnify and hold harmless the Department and its officers and employees and Municipalities and its officers and employees from claims, suits, actions, damages and costs of every nature arising out of the provision of services pursuant to this AGREEMENT and under the EIP.
  2. The Provider is an independent contractor and may neither hold itself out nor claim to be an officer, employee or subdivision of the Department or Municipality nor make any claims, demand or application to or for any right based upon any different status.
This provision shall survive the termination of this Agreement. This Agreement shall be deemed terminated immediately upon the Provider´s failure to comply.
Terms and Termination

This Agreement shall be effective for a five (5) year term, unless terminated pursuant to the terms hereof. Provider shall not provide services, nor hold itself out as authorized to provide such services on and after the date upon which this Agreement shall be deemed terminated.

If the Provider wishes to continue participating the EIP after the expiration of this Agreement, Provider shall notify the Department at least ninety (90) days prior to the expiration date and request that the Department enter into a new agreement with the Provider.

Amendments to this agreement may be made by the Department and shall be sent to the Provider via mail or electronically utilizing the Provider´s email address. The Provider shall notify the Department within thirty (30) calendar days of the date the Provider receives the proposed Amendment of whether it accepts the terms contained in the proposed Amendment. The Department reserves the right to terminate this Agreement if a proposed Amendment is not accepted. Oral modifications to this Agreement are prohibited.
1. Termination for Convenience by the Department:
  This Agreement may be cancelled at any time by the Department giving to the Provider not less than ninety (90) days written notice that on or after a date therein specified this Agreement shall be deemed terminated and cancelled. Provider shall not render services in the EIP on and after the date specified in such notice and shall not claim for any services rendered after such termination date.
2. Termination for Convenience by Provider:
  This Agreement may be cancelled at any time by the Provider giving to the Department not less than ninety (90) days written notice that on or after a date therein specified this Agreement shall be deemed terminated and cancelled. In the event the Provider terminates the Agreement in accordance with this paragraph, Provider shall, together with any notice of termination, provide each child´s Service Coordinator and the corresponding Municipality of residency of the children served with a Plan and Timetable for the orderly transition of services, and a copy of any proposed notification to parents, transporters, employees and Individual Providers utilized by an Agency Provider who deliver services. The plan and timetable for orderly transition of services must be developed in conjunction with affected municipalities and municipal procedures. Notification to parents, transporters, employees and Individual Providers utilized by an Agency Provider shall be disseminated by the Provider upon approval by the Municipality and the Department of the proposed Plan and Timetable. The notice of termination and transition plan shall be submitted to the service coordinator(s), Municipality and the Department not less than ninety (90) calendar days prior to the intended termination date of the Agreement.
3. Termination for Cause:
  The Department or the Provider may terminate this agreement prior to the end of term by giving thirty (30) calendar days written notice to the other party of its intention and reason for termination. The non–terminating party may be given an opportunity to cure the reason for termination within the 30 day period. If the non–terminating party does not cure the reason for termination to the satisfaction of the terminating party, this Agreement shall terminate at the end of such 30 day period. Cause for termination may include but shall not be limited to: (a) failure to comply with the terms and conditions of this Agreement; and (b) any violation of applicable laws or regulations, including an unacceptable practice under the Medical Assistance Program as enumerated in Title 18 NYCRR §515.2. Provider shall immediately provide each child´s individual Service Coordinator and the corresponding Municipality of residency of the children served, with a Plan and Timetable for the orderly transition of Services, and a copy of any proposed notification to Parents, transporters, employees and independent contractors utilized by a provider agency who deliver EI provider services. The plan and timeline for orderly transition of services must be developed in conjunction with municipal procedures. Notification to parents, transporters, employees and independent contractors utilized by a Provider Agency shall be disseminated by the Provider Agency upon approval by the Municipality and the Department of the proposed Plan and Timetable.
4. Immediate Termination by the Department:
  The Department shall have the right to terminate this Agreement, in whole or with respect to any identifiable part of the Program, effective immediately in cases of imminent danger to the health and safety of Eligible Children, Parents and/or staff, or upon the filing of a petition in bankruptcy or insolvency, by or against the Provider. Such termination shall be immediate and complete, without termination costs or further obligations by the Department or Municipality to the Provider.
5. Compliance Involving Health & Safety Issues:
  If the Department finds that the health or safety of a child, the child´s parents or staff of the Agency Provider or Municipality is in imminent risk of danger or there exists any condition or practice or a continuing pattern of conditions or practices which poses imminent danger to the health or safety of such child, parents or staff of the Agency Provider or Municipality, in addition to any other remedies available to it, the Department may:
  1. terminate this Agreement,
  2. terminate one or more of the service models the Provider is authorized to deliver in the EIP,
  3. terminate one or more service delivery methods/settings;
  4. direct that the Municipality prohibit or limit the assignment of children to the Provider;
  5. direct that the Municipality remove or cause to be removed some or all of the children the Provider currently serves;
  6. direct that the Municipality suspend or limit or cause to be suspended or limited payment for services to the Provider.
6. Notices:
  All notices shall be sent to the Provider listed within the electronic data system (NYEIS) as the Program Director or in the case of an Individual Provider to the address provided by Provider. All notices of termination will contain the specific date on which the Provider must cease providing Early Intervention Services.
  All notices from the Provider must be sent to the Department at the following address:
  
  New York State Department of Health
  Bureau of Early Intervention
  Provider Approval & Due Process Unit
  ESP, Corning Tower, Room 287
  Albany, New York 12237–0660
7. Severability:
  It is expressly agreed that if any term or provision of this Agreement, or the application thereof to any person or circumstance, shall, to any extent, be held invalid or unenforceable, the remainder of this Agreement, or the application of such term or provision to persons or circumstances other than those as to which it is held invalid or unenforceable, shall not be affected thereby; and every other term and provision of this Agreement shall be valid and shall be enforced to the fullest extent permitted by law.

Appendix 1 – Payee Provider Agreement/Service Authorizations and Payment

THIS Appendix IS NOT CONSIDERED TO BE FULLY EXECUTED WITHOUT AN APPROVAL DATE FROM THE New York State Department of Health. The Provider cannot receive service authorizations from a Municipality and bill for early intervention services rendered until this Appendix is fully executed by the Department. In the event this Appendix is executed subsequent to the execution of the Agreement, the effective dates for this Appendix shall be as set forth herein.

For a Provider to receive service authorizations from a Municipality for EIP services and direct payment for the services rendered from the Municipality, the Provider shall utilize the Department´s NYEIS data system and, when indicated by the Department, establish a relationship with the Department´s fiscal agent for claiming payment for service coordination, evaluations and EI Provider services. Provider shall comply with all requirements for billing as required in applicable law and regulation, and as necessary for the fiscal agent to perform its duties, including but not limited to, the terms and conditions set forth in this Appendix.
1. Provider shall not bill or collect payment from the family directly for EI services nor require the family to pay additional costs.
2. Provider shall promptly notify the Department and/or its state fiscal agent and the Municipality of any duplicate or erroneous payment received from the Municipality or from any third–party payor and cooperate with the Department and/or its state fiscal agent and the Municipality to rectify the situation.
3. Provider shall enroll in the Medical Assistance Program as a billing Provider for EIP services.
4. Provider shall, for children who have coverage under an insurance policy, plan or health benefit package, including the Medicaid Assistance Program or other governmental payor, seek payment from such insurer or health plan prior to seeking payment from the Municipality, in accordance with PHL § 2559. Provider shall utilize the Department´s data system and/or fiscal agent as directed by the Department in seeking payment from such insurer or health plan. Provider shall further take the appropriate steps to secure insurer or health plan payment for services, including responding to claim denials by correcting any errors identified in claims, providing requested documentation such as that needed to support medical necessity, and the submission of Subrogation notice to each child´s insurance company.
5. The Department and/or its fiscal agent(s) will assume responsibility for management of all provider bills on April 1, 2013. Provider shall use uniform and consistent procedures as directed by the Department for submission of bills associated with children whose records reside in KIDS. Provider shall use the Department´s data system for submission of bills associated with children whose records reside in NYEIS.
6. The Department and/or its fiscal agent(s) will assist Provider in claims submission and adjudication to third party payors, and shall manage payments owed to Provider for services not reimbursed by third party payors.
7. Provider shall maintain progress and session notes detailing the nature and extent of services provided and shall make them available to the Department and/or Municipality upon request for programmatic monitoring and fiscal audit purposes.
8. Provider shall have policies and procedures in place to verify that any service authorizations issued by the Municipality are in conformity with the IFSP and to notify the service coordinator and Municipality immediately regarding any discrepancy. Provider shall further develop and implement policies and procedures to verify that services are delivered to a child in conformity with the child´s IFSP.
9. Provider shall keep an accurate record of attendance for each child for whom services are being provided. Such record shall be maintained in the child´s record or file and may be requested at any time by the Department or Municipality.
10. Provider shall make available and accessible to the Department and Municipality, all records and information necessary to assure the appropriateness of payments made to the Provider and to assure the Provider´s compliance with all applicable statutes and regulations.
11. Provider understands and agrees that payment will not be made for services provided by individuals who are not qualified personnel as defined in 10 NYCRR §69–4.1(ak), or for services rendered by qualified personnel who are not acting within the scope of practice authorized by his or her license, registration or certification for the provision of services authorized in a child´s IFSP
12. Provider shall fully familiarize itself with Department´s policy and guidance regarding billing and documentation for services rendered.
13. Provider shall submit to the Department no less than annually in a manner and format and by the date requested by the Department, a description of the Provider´s services at each site at which EI Provider services are offered. Such program description may include program models utilized at various sites, languages offered, services offered, special populations served, and other such description information. The Department shall make such program descriptions available to Service Coordinators for the purpose of assisting parents in understanding program types and options, and in selecting an evaluation site.
14. Pursuant to PHL § 2557, when directed by the Department, Provider shall utilize the Department´s fiscal agent for early intervention claims as determined by the Department. Provider shall provide such information and documentation as required by the Department and necessary for the fiscal agency to carry out its duties.
Additional Requirements: Provider shall not commence performing Services under this Agreement plus Appendix 1 unless and until all required insurance is in effect, and shall ensure continuous insurance coverage in the manner, form, and limits required by the Agreement.
1. Provider shall procure, pay the entire premium for and maintain throughout the term of this Agreement insurance in amounts and types specified herein. Unless otherwise specified by the Department and agreed to by the Provider, in writing, such insurance will be as follows:
  1. Commercial General Liability insurance including contractual coverage, in an amount no less than $1,000,000/per occurrence.
  2. Automobile Liability insurance (if any vehicles are used in the performance of this Agreement) in an amount not less than $1,000,000 combined single limit for bodily injury and property damage occurrence.
  3. Professional Liability insurance in an amount not less than $1,000,000 per incident/occurrence.
  4. In the case of Agency Providers, Worker´s Compensation and Employer´s Liability insurance in compliance with all applicable New York State laws and Regulations and Disability Benefits insurance, if required by law. Provider shall furnish to the Department, prior to its execution of this Agreement, the documentation required by the New York State Workers´ Compensation Board of coverage or exemption from coverage pursuant to Sections 57 and 220 of the NYS Workers´ Compensation Law. In accordance with Article 5–A Section 108 of NYS General Municipal Law, this Agreement shall be void and of no effect unless the Provider shall provide and maintain coverage during the term of this Agreement for the benefit of such employees as are required to be covered by the provisions of the Workers´ Compensation Law.
2. To have all policies providing such coverage issued by insurance companies with an A.M. Best rating of A– or better.
3. To furnish to the State certificates of insurance or, on request, original policies, evidencing compliance with the aforesaid insurance requirements.
4. To have, in the case of commercial liability insurance, said certificates or other evidence of insurance name the State of New York and Municipality as an additional insured.
5. To have all such certificates or other evidence of insurance provide for the State of New York and Municipality to be a certificate holder and to be notified in writing thirty (30) days prior to any cancellation, non–renewal or material change.
6. To have such certificates, policies or other evidence of insurance and notices mailed to the Department and Municipality at the address contained in this Agreement or at any such other address of which the Department and Municipality shall have given the Provider notice in writing.
Additional Requirements: Upon request of the Department, Individual Providers shall provide the Department with all necessary information and documentation to allow for clearance from the State Central Register (SCR), and shall further submit the fee required by Section 424–a of New York State Social Services Law to perform such SCR clearance.

H/23/S/NYS Agreement/Final/Provider Agreement October 2013

New York State Department of Health
Bureau of Early Intervention

Early Intervention Provider Agreement

Signatory must be legally authorized to enter into an Agreement on behalf of the Provider.

I have read and understand my obligations as stated in this Agreement. ☐ Yes

My request includes the terms outlined in Appendix 1 (check one):

☐ Yes ☐ No

In Witness Whereof, the parties hereto have executed* this Agreement as of the latest date written below.

Provider Name

Agency Name/Individual Provider Name

NYS Provider ID/State ID

First Name
____________________________________

M.I.
_________

Last Name
_____________________________________

Address

Street Address			Apartment/Floor
City	State	Zip Code (9 digit) https://tools.usps.com/go/ZipLookup	County (if in NY)
E–mail Address		NPI

Service Catchment Area(s): Circle all counties/municipalities for which you are available to provide services.

Albany	Fulton	Orange	Tioga
Allegany	Genesee	Orleans	Tompkins
Broome	Greene	Oswego	Ulster
Cattaraugus	Hamilton	Otsego	Warren
Cayuga	Herkimer	Putnam	Washington
Chautauqua	Jefferson	Rensselaer	Wayne
Chemung	Lewis	Rockland	Westchester
Chenango	Livingston	St. Lawrence	Wyoming
Clinton	Madison	Saratoga	Yates
Columbia	Monroe	Schenectady
Cortland	Montgomery	Schoharie	New York City Area
Delaware	Nassau	Schuyler	Bronx
Dutchess	Niagara	Seneca	Kings
Erie	Oneida	Steuben	New York
Essex	Onondaga	Suffolk	Queens
Franklin	Ontario	Sullivan	Richmond

Authorized Signature
Title	Telephone

Approved By New York State Department of Health
(Insert name of Department Representative)

First Name	Last Name
Authorized Signature	Approval Date
Dates of Agreement Effective: Expiration:	A1 Yes No

*THIS Appendix IS NOT CONSIDERED TO BE FULLY EXECUTED WITHOUT AN APPROVAL DATE FROM THE New York State Department of Health. The Provider cannot receive service authorizations from a Municipality and bill for early intervention services rendered until this Appendix is fully executed by the Department. In the event this Appendix is executed subsequent to the execution of the Agreement, the effective dates for this Appendix shall be as set forth herein.

2018

Department of Health

New York State Department of Health, Bureau of Early Intervention

Application for the Approval of Agencies

As Early Intervention Evaluators, Service Coordinators & Service Providers

Who May Apply for Approval as an Early Intervention Agency:

Minimum Agency Staffing Requirements:

Written Plans

How to Apply for Approval as an Early Intervention Agency:

The Review of your Agency Application/Provider Agreement for the Approval of Agencies as Early Intervention Evaluators, Service Coordinators & Service Providers:

The following references may be of assistance when completing this application:

Application Instructions

SCHEDULE 1 – BACKGROUND INFORMATION

SCHEDULE 2 – Corporate Structure/Disclosure Requirements

SCHEDULE 3 – DISCLOSURE INFORMATION – all three pages must be completed by each individual identified in Schedule 2. This form may be duplicated as necessary.

SCHEDULE 4 – APPLICANT AGENCY AFFILIATION

A. Health, Education, Developmental Disabilities, and Mental Hygiene Agencies

B. Managed Care Plan Affiliations

SCHEDULE 5 –PERSONNEL

A. Available Personnel

B. Personnel Information

SCHEDULE 6 – SERVICE AVAILABILITY

A. Services

B. Languages and Other Forms of Communication

C. Specialized Services

SCHEDULE 7 – FACILITY SITESComplete a copy of this schedule for each facility site operated by the applicant agency.

Name/Address of Site

Early Intervention Service Model Options

Health and Safety Policy

Child Care Providers

SCHEDULE 9 – ASSURANCES

ACKNOWLEDGMENT

Notarization

Definitions

APPLICATION CHECKLIST

NYS Department of Health Bureau of Early InterventionProvider Approval and Due Process UnitAgency´s Officers/Employees/Contractors

Officers/Stakeholders

Employees/Contractors Available to Provide Direct Services:

New York State Department of HealthBureau of Early Intervention

Early Intervention Provider Agreement

Purpose of Agreement

Definitions

Appendix 1 – Payee Provider Agreement/Service Authorizations and Payment

New York State Department of HealthBureau of Early Intervention

Early Intervention Provider Agreement

Department of Health

General Information

Current Issues/Info

Help

Language Assistance

CONNECT WITH US

SCHEDULE 7 – FACILITY SITES

Complete a copy of this schedule for each facility site operated by the applicant agency.

NYS Department of Health Bureau of Early Intervention
Provider Approval and Due Process Unit
Agency´s Officers/Employees/Contractors

New York State Department of Health
Bureau of Early Intervention

New York State Department of Health
Bureau of Early Intervention