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Insurance Tool Kit for Service Coordinators - Fillable PDF Forms - Corrected

 New York State Department of Health

New York Early Intervention System (NYEIS) Electronic Mailing List

Insurance Tool Kit for Service Coordinators - Fillable PDF Forms - Corrected


Dear Colleague:
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*Please note, a minor correction was made to the forms described in the announcement below and attached to this e-mail. Please use this version.

The Department of Health is pleased to provide the attached document containing Forms A-F from the Insurance Tool Kit for Service Coordinators in a fillable PDF format.  The Department received several requests from the field indicating that fillable forms would improve efficiency for Service Coordinators.  The Department is pleased to disseminate these forms.

The forms contain many common fields, e.g., Child's Name, Child's Date of Birth, Name of Parent, Insurance Company, etc.  The  forms are fillable and will populate all fields that are an exact match.  Please follow the instructions provided below:

  • To begin, place the cursor on the field (box) you wish to complete.
  • To advance from one field (box) to the next use the TAB key, not the ENTER key.
  • If a field requires more than one line of text, please use the ENTER key not the TAB key to move from one line to the next within the same field (box).  Examples below:
    • Address fields have room for more than one line.
    • Form B - Notice of Parent Declination to Provide Insurance Information has adequate space for text.  There are no visible lines in this field (box). You may use the ENTER key to advance from one line to the next.
  • Please note that Form D asks for Child’s Name in a different format - Child’s Name (First/MI/Last), so this field will not automatically pre-populate from previously entered text. 
The form can be opened by clicking on the link HFormsComplete Insurance Tool Kit Fillable Forms Final V2_C.pdf

Please do not reply to this e-mail announcement.

Thank You.

Article ID: 148, Created On: 3/26/2014, Modified: 10/28/2015

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