APPENDICES FORMS Word Documents EI 5031 ATD Request EI ...

Nassau County Department of Health Assistive Technology
Early Intervention Program Request & Authorization
Preschool Special Education Program
INSTRUCTIONS FOR ASSISTIVE TECHNOLOGY REQUEST
1. Therapist/Evaluator to complete Section I and/or II and III.
2. A separate form must be completed for each requested device and/or service.
3. For custom devices attach a written cost estimate.
4. Attach the Amendment/Justification Form.
5. Attach a prescription for each requested device.
6. All devices will be reimbursed at the current Medicaid rates.
INCOMPLETE FORMS will NOT be considered for review and will be returned to therapist/evaluator.
Only original forms will be accepted. NO FAXES or copies.
Medicaid #: __
Child/s Name: E.I.O.D.:
Address: Address: Nassau County Department of Health
60 Charles Lindbergh Blvd, Suite 100
Telephone: DOB: Uniondale, NY 11553-3683
Parent/Guardian Name: Telephone: 516-227- Date:
SECTION I - REQUESTED DEVICE
Description: Vendor Name:
CPT Code: Cost:
Address:
Telephone:
SECTION II - REQUESTED SERVICES
Description: Provider Name:
Address:
CPT Code: Cost: Telephone:
SECTION III - REQUESTED BY
Name: Title: Date:
Agency Name:
Agency Address:
Signature: Telephone:
NASSAU COUNTY DEPARTMENT OF HEALTH AUTHORIZATION
[ ] Authorized on: [ ] Denied on:
Signature: Title:
KIDS Authorization # Check Date:
Voucher #: Verified By:
Check #: Batch #:
EI 5031 5/06