7013 ITP Written Consent - North Carolina



North Carolina Infant-Toddler Program

Prior Written Notice and

Consent for Evaluation and Assessment

|Child’s Name: |      |Date of Birth: |      |

| | | | |

|Reason for Prior Written Notice: This is to notify you that federal and state regulations require the North Carolina Infant-Toddler Program to provide |

|ten (10) days prior written notice to conduct evaluation and assessment activities. You may agree to have the proposed action(s) occur sooner and not wait|

|the ten (10) days. |

| |

|Select the appropriate actions for which prior written notice is provided and consent is sought |

| |

|ELIGIBLITY EVALUATION |CHILD ASSESSMENT |

|Proposed Action: |Proposed Action: |

|Initial Evaluation to determine eligibility OR |Initial Child Assessment OR |

|Evaluation after enrollment to determine ongoing eligibility |Child Assessment after enrollment to assist with intervention planning |

|Action: Eligibility Evaluation | |

|Reason: The purpose of evaluation is to determine your child’s initial or |Action: Child Assessment |

|ongoing eligibility for the NC Infant-Toddler Program (NC ITP). |Reason: A child assessment for eligible children is conducted prior to the |

| |initial development of the IFSP to inform intervention planning. Additional |

| |assessments may be conducted after enrollment as needed to assist with |

| |ongoing intervention planning. |

| |

|Consent for Eligibility Evaluation |Consent for Child Assessment |

| |

|I have been fully informed of all information relevant to the eligibility |I have been fully informed of all information relevant to the child |

|evaluation. I understand my consent is voluntary and may be revoked in |assessment. I understand my consent is voluntary and may be revoked in |

|writing at any time. I understand that my child will not receive the |writing at any time. I understand that my child will not receive the |

|eligibility evaluation unless I give my written consent. |assessment unless I give my written consent. |

|_____ (initial) I give my consent for the NC ITP to carry out the eligibility|_____ (initial) I give my consent for the NC ITP to carry out the assessment |

|evaluation as described above. |as described above. |

|Consent to Bill Insurance / Medicaid |

|_____ (initial) I have received a copy of the NC ITP System of Payment Notification. The notifications related to billing private and public insurance |

|benefits have been explained to me and I understand them. |

|_____ (initial) I understand that evaluation, assessment and service coordination activities are provided at no cost to all families, regardless of consent|

|for billing private or public insurance benefits. |

| |

|I Do I Do Not give consent for the NC ITP and authorized service providers to bill the private insurance and / or public insurance (Medicaid), on |

|record for my child, for the Eligibility Evaluation and/or Child Assessment (and related service coordination activities as applicable prior to initial |

|IFSP development). I authorize the release of medical or clinical information necessary to process the insurance claim. If my child is covered by private |

|insurance and Medicaid, I understand that Medicaid policy is that private insurance must be billed first, before Medicaid benefits can be accessed. |

| |Parent Signature | |Date | |

|Parental Notice of Child and Family Rights and Procedural Safeguards: A copy of | |For CDSA Use (check and complete all that apply): | |

|the North Carolina Infant-Toddler Program Notice of Child and Family Rights | | | |

|document is provided to you and pertinent rights and procedural safeguards are | | | |

|reviewed and explained as an accompaniment to all prior written notice forms. This | | | |

|information includes all the procedural safeguards that are available, including a | | | |

|description of mediation, due process and state complaint procedures and the | | | |

|timelines for those procedures. | | | |

| | | |Notice mailed on |      | |

| | | |Notice hand-delivered on |      | |

| | | |Parent agreed on |      | |

| | | |to have the proposed action(s) occur sooner and not | |

| | | |wait the ten (10) day prior notice time. | |

North Carolina Infant-Toddler Program

Prior Written Notice and

Consent for Evaluation and Assessment

Purpose: To obtain parent acknowledgement that the family has received written notification of their rights and that these rights and procedural safeguards have been explained;

To obtain written parental consent for the evaluation to determine eligibility and/or assessment to assist with intervention planning; and

To give prior written notice to the family for evaluation activities.

Instructions: Enter child’s name and date of birth;

Consent for Action(s): Select the appropriate actions for which prior notice and consent is being sought and place a check in the appropriate boxes. This can be evaluation and/or assessment. Be sure to direct the parent to initial one or both places (evaluation and assessment) if appropriate.

Consent for billing: Consent to use a family’s insurance must be obtained prior to billing insurance for any early intervention services; and each time consent for services is required due to an increase (in frequency, length, duration, or intensity) in the provision of services in the child’s IFSP. Notification of child and family rights and related financial policy using the NC ITP System of Payment Notification must occur whenever consent for the use of insurance is requested. Parents should initial the line to confirm that they have received a written copy of the NC ITP System of Payment Notification and that the notifications related to billing private and public insurance benefits have been explained and they understand them. The EI Service Coordinator should review with the parent all pertinent notifications, rights, and safeguards related to use of insurance benefits and consent for use of insurance.

When applicable, parents should initial the line to confirm they understand that when covered by private insurance and Medicaid, that under Medicaid policy private insurance must be billed first, before Medicaid benefits can be accessed.

Once all notification, rights, and safeguards have been explained, the parent, or parent surrogate, should use the appropriate check boxes to indicate consent instructions for use of insurance including any exceptions.

For CDSA Use Box: Document the date the prior notice was mailed or hand-delivered to the parent. The family should be given ten days prior notice unless they agree to have the evaluation occur sooner. The family must be given a copy of the notice even if they agree to not wait the ten days.

File completed form in the child’s record. Mail or hand-deliver a copy of the notice to the parent.

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