Application for Approval of Agencies or Incorporated Groups of Individuals as Evaluators, Service Providers and Service Coordinators

Instructions

Introduction

The process herein described is for the approval of agencies as early intervention evaluators, service providers and service coordinators for the statewide Early Intervention Program under Title II-A of Article 25 of the Public Health Law. The following references may be of assistance when completing the application:

Submit ONE signed copy of the completed application to the address below and make a copy for your records. Application must contain original signatures authorizing the application.

New York State Department of Health
Bureau of Early Intervention
Empire State Plaza
Corning Tower, Room 287
Albany, New York 12237 – 0660

An agency which is an approved program under §4410 of the Education Law may apply to either the Department of Health (at the address above) or the State Education Department at the following address:

New York State Department of Education
Office of VESID
One Commerce Plaza, Rm. 1624
Albany, NY 12234

Approval Process

The applicant must submit a completed application with original signatures and all required information. Staff within the state early intervention agency will review the application for completeness. If the application is incomplete the application, and all attachments, will be returned and the applicant will be notified by letter specifying what information is required for completion. Once an application is determined to be complete, it will be reviewed and the agency will receive written notification of approval or disapproval.

Inquires concerning the application or approval process can be directed to either:

  • Department of Health, Bureau of Early Intervention (518) 473-7016
  • Department of Education (518) 486-7584

Schedule 1 – General Agency Information

  1. Agency name and address: enter the legal name, address and tax identification number (9 digits) of the agency seeking approval. The name entered must correspond exactly with the name appearing on the agency's organizational documents. In the case where the provider has multiple program sites, the agency name refers to the administrative office of the agency (main site).
  2. Service delivery site: enter the name and address of all sites if different from main site. If there is more than one service site, list the name, address and phone number of each site where early intervention services will be provided. Attach separate sheet if necessary.
  3. Name and title of contact person: enter the name of the person who is responsible to provide information regarding the application (person must be located at the main agency office).

Schedule 2 – Operator Information

  1. Enter the name, title and business address of the operator of the agency.
  2. Record of legal actions: except for minor traffic violations, describe any criminal or other charges of which the operator has been convicted or which are pending. "Other Charges" may refer to charges of both a criminal and civil nature, including malpractice or child abuse or maltreatment.
  3. Type of Ownership: check only one.
    All incorporated entities, sole proprietorships, partnerships, and state-operated facilities must submit copies of all organizational documents, such as partnership agreements or certificates of incorporation and filing receipts. If using a d/b/a (doing business as) and the name does not appear on the organizational documents, you must attach a "Certificate of Assumed Name" with the application.
  4. Class of Operator: check only one.

Schedule 3 – Agency Affiliation

  1. Indicate either yes or no if the agency is approved by any of the state early intervention service agencies (1 through 6).

    Indicate in what capacity the agency is approved by any of the state early intervention service agencies (e.g., hospital, certified home health agency, clinic, day treatment program, etc.).

    Indicate the latest date of site visit or program review, or planned site visit or program review by a state early intervention agency.

  2. Indicate either yes or no whether agency has ever had its approval revoked by any of the state early intervention service agencies. If "yes" provide the date of action, reason for action, the resolution of such action, and whether the approval has been reinstated.

Schedule 4 – Project Outline

  1. Proposed Services: indicate the services for which the agency is seeking approval including:
    1. Evaluation Services: Core and Supplemental: indicate if the agency is seeking approval to provide multidisciplinary evaluations. This requires availability of a licensed physician who must be included in Schedule 5, Qualified Personnel (a Letter of Agreement from the physician on their letterhead should be attached);
    2. Supplemental Evaluation Services Only;
    3. Service Coordination Services;
    4. Service Provider: Indicate for which service models (a through e) the agency is seeking approval. If (b) is checked (facility-based), you must include a copy of Health, Safety and Fire Evacuation Procedures.
  2. Languages spoken by staff in agency: indicate the language(s), other than English, spoken by staff in the agency providing early intervention services.
  3. Service catchment area and population served: indicate all counties for which the agency is seeking approval to provide early intervention services at time of application.
  4. Special populations: indicate if there is a category of infants and toddlers with disabilities to which the agency plans to provide early intervention services (e.g., sensory impairment). Attach separate sheet if necessary.

Schedule 5 – Qualified Personnel

  1. Indicate the availability in full-time equivalents (FTE) based on a 40-hour week of all qualified personnel.

    The number of personnel should be reported in full time equivalency of availability to provide services to infants and toddlers and their families (e.g., if two half-time personnel are employed, they would equal one full-time equivalent employee). If personnel work with children of all ages, report only that portion of time spent with infants and toddlers ages birth to three years of age with disabilities (e.g., a person who works with infants and toddlers with disabilities and their families 20 percent of the time would be counted as .2 FTE).

  2. If qualified personnel are available through contract, attach separate sheets including the name, address and social security number of each contractor and the type of contract (e.g., open-ended, yearly). Agencies may only contract with approved early intervention providers.

Schedule 6 – Assurances

To receive approval, the agency must provide assurance of compliance with all regulations and assurances "A" through "H". The "Authorizing Signature" certifies that information contained in the application is correct, and that the agency is in compliance with all assurances. Signatures must be originals and application must be notarized.

Definitions

Approved
Approved refers broadly to any type of process used by state early intervention service agencies to authorize service providers to deliver health and human services. These processes may include licensure, certification, or procedures otherwise specified in regulations promulgated by that agency.
Caregiver
Caregiver refers to an individual responsible for the care of the child such as a parent, child care provider or babysitter.
Evaluation
Evaluation refers to the procedure used by appropriate qualified personnel to determine a child's initial and continuing eligibility for the Early Intervention Program, including determining the status of the child in each of the following areas of development: cognitive, physical, communication, social or emotional, and adaptive development.
Multidisciplinary
Multidisciplinary refers to the involvement of two or more different disciplines in the provision of integrated and coordinated services, including evaluation and assessment services and development of the Individualized Family Service Plan.
Natural Environment
Natural environment refers to settings that are natural or normal for the child's age peers who have no disability, including the home, a relative's home when care is delivered by the relative, child care setting, or other community setting in which children without disabilities participate.
Qualified Personnel
Qualified personnel refers to those individuals who are approved as required to deliver services to eligible children birth through two years of age to the extent authorized by their licensure, certification or registration, and have appropriate licensure, certification, or registration in the area in which they are providing services, including the following personnel:
  1. audiologists;
  2. certified occupational therapy assistants;
  3. licensed practical nurses, registered nurses and nurse practitioner;
  4. certified low vision specialists;
  5. occupational therapists;
  6. orientation and mobility specialists;
  7. physical therapists;
  8. physical therapy assistants;
  9. pediatricians and other physicians;
  10. physicians' assistants;
  11. psychologists;
  12. school psychologists;
  13. registered dieticians;
  14. social workers;
  15. special education teachers;
  16. speech and language pathologists and audiologists;
  17. teachers of the blind and partially sighted;
  18. teachers of the deaf and hearing handicapped;
  19. teachers of the speech and hearing handicapped;
  20. other categories of personnel as designated by the Commissioner.
Screening
Screening refers to those instruments, procedures, family information and observations, and clinical observations used by an approved evaluator to assess a child's developmental status to indicate what type of evaluation, if any, is warranted.

Models of Early Intervention Service Delivery:

  1. Home and Community Based Individual/Collateral Visits
    Home and community based individual/collateral visits refers to the provision by appropriate qualified personnel of early intervention services to the child and/or parent or other designated caregiver at the child's home or any other natural environment.
  2. Facility-based Individual/Collateral Visits
    Facility-based individual/collateral visits refers to the provision by appropriate qualified personnel of early intervention services to the child and/parent or other designated caregiver at an approved early intervention provider's site.
  3. Parent-child Groups
    Parent-child groups refers to a group comprised of caregivers, children and a minimum of one appropriate qualified provider of early intervention services at an early intervention provider's site or a community-based site (day care centers and family day care homes).
  4. Group Developmental Intervention
    Group developmental intervention refers to the provision of early intervention services by appropriate qualified personnel to a group of eligible children at an approved early intervention provider's site or in a community-based setting where children under three years of age are typically found (this group may also include children without disabilities).
  5. Family/Caregiver Support Group
    Family/caregiver support group refers to the provision of early intervention services to a group of parents, caregivers (foster parents, day care staff, etc.) and/or siblings of eligible children for the purpose of:
    1. enhancing their capacity to care for and/or enhance the development of the eligible child;
    2. providing support, education and guidance to such individuals relative to the child's unique developmental needs.