Get Nyc Early Intervention Program Assistive Technology Medical Necessity Justification Form 2015-2025

Completing the NYC Early Intervention Program Assistive Technology Medical Necessity Justification Form is essential for obtaining necessary assistive technology for children with developmental needs. This guide provides a step-by-step approach to ensure accurate and efficient submission of the form online.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Begin by filling in the child's identifying information, including their name, date of birth, and Early Intervention number. Ensure this information matches what is in the NYC Early Intervention System (NYEIS).
3. Indicate the service type and location where services will occur. This helps in understanding the context in which the assistive technology will be used.
4. Document the child’s diagnosed condition(s) and provide the corresponding ICD-10 codes to support the medical necessity of the requested device.
5. Enter the Individual Rendering Provider’s name and credentials. This identifies the professional responsible for recommending the assistive technology.
6. Specify whether the child and caregiver can travel to the vendor location by selecting 'Yes' or 'No'.
7. Complete the section regarding your contact with the TRAID Center Loan Closet, including the date of contact and the outcome. You must check one of the provided options regarding the availability of the device.
8. List the requested assistive technology device (ATD) category and justify why it is necessary for the child’s functional skills. Detail any accessories needed and their justifications.
9. Document the existing and new functional outcomes from the Individualized Family Service Plan (IFSP) that the requested ATD will address.
10. Describe how the requested ATD will support the child’s functional capabilities and meet their unique developmental needs.
11. Indicate any precautions concerning the child’s medical condition that may impact the device's safe use.
12. Explain how the ATD will be integrated into the child and family’s daily routines, specifying settings for use and types of activities.
13. Detail any lower-tech devices discussed or used prior to this request and explain why they are not suitable.
14. Identify any other assistive technology devices currently in use by the child and their compatibility with the requested device.
15. Outline how you will collaborate with other providers in using the proposed ATD, including discussions about its application and goals.
16. List parents or caregivers who require training on the device and outline the training's necessary components.
17. Have both the parent/caregiver and the Individual Rendering Provider sign the form, including the provider’s license and direct contact information.
18. Once all sections are completed, ensure to save changes, download, print, or share the form as needed.

Take the first step towards securing essential assistive technology by completing the necessary documentation online today.