NYS EARLY INTERVENTION PROGRAM CONSENT FOR THE USE OF TELEHEALTH DURING DECLARED STATE OF EMERGENCY FOR COVID-19

NYS EARLY INTERVENTION PROGRAM CONSENT FOR THE USE OF TELEHEALTH DURING DECLARED STATE OF EMERGENCY FOR COVID-19
Child’s Name:
EI#:
DOB:
Address:
Apt #:
City/Town:
Zip Code:
Services Type to Be Delivered Using Telehealth:
NYEIS Service Authorization #:
Name of Therapist/Teacher:
Phone #:
NY Therapy Placement Services, Inc.
Phone #:
Service Coordinator
Phone #:
Service Coordinator Agency
Phone #:
Instructions: A consent form, such as this sample for the use of telehealth as an early intervention service

delivery method, must be completed for each service type authorized for the child including evaluation services

before telehealth services can be initiated. Telehealth as an early intervention service delivery method is only

available during the declared state of emergency for COVID-19. A consent form for the use of telehealth can be returned by email if the parent/guardian also signs and returns the Parental Consent to Use E-mail to Exchange Personally Identifiable Information Form, available here:

https://www.health.ny.gov/community/infants_children/early_intervention/memoranda/docs/early_intervention

_parent_consent_to_use_email.pdf

The consent form for the use of telehealth must be attached to the child’s integrated case in NYEIS. A separate consent form is required for each early intervention service.
I, (Parent/Guardian’s Full Name)
(enter service type)
service delivered using telehealth as an early intervention

service delivery method. I understand that the telehealth services that my child will be receiving will fulfill the service mandate in my child’s Individualized Family Service Plan (IFSP) and are not being delivered in addition to the home/community-based services that my child is authorized to receive.

I understand that telehealth as an early intervention service delivery method is only available during the declared state of emergency for COVID-19 and that my child’s services will be delivered using the method authorized in my child’s IFSP after the declared state of emergency for COVID-19 ends.

I understand that telehealth means that early intervention services will be delivered using an audio and video at the same time for the duration of the session. Telehealth does not mean having a telephone call with my child’s therapist/teacher.

I understand that I will have access to all early intervention information resulting from the sessions conducted via telehealth in the form of Session Notes and Progress Notes if I request them from my child’s Service Coordinator.

I have received a copy of “Your Family Rights in the Early Intervention Program”.
Parent Name
Parent Signature

Clear
Date
Should be Empty: