Early Intervention Program Memorandum 2003-1 Early Intervention Program Records

Table of Contents

• Background
• General Requirements for Early Intervention Program Records
  • Responsible Parties
  • Content of Records
    • Applicable Definitions
    • Programmatic Content
    • Documentation Necessary for Billing and Claiming Purposes
    • Service Coordination Logs
    • Coordination, Location, and Organization of Records Pertaining to Individual Children
• Use of Electronic Records and Signatures
• Procedural Safeguards Pertaining to Early Intervention Records
  • Confidentiality
  • Access to Records
    • Disclosure
    • Consent for Exchange of Information
    • Sensitive Information/Information Extraneous to Early Intervention
    • Medicaid Information
    • Parental Access to Their Children's Records
    • Requirements When Early Intervention Providers Also Operate Other Programs
    • Requirements for Children In Foster Care
  • Amending the Record
• Retention of Records
• Questions and Answers
• Appendix A - Summary of FERPA Requirements
• Appendix B - Examples of Documents Generated by Municipalities
• Appendix C - Examples of Documents Generated by Early Intervention Providers
• Appendix D - Sample Session Note
• Appendix E - Checklist for Early Intervention Records
• Appendix F - Medicaid Requirements for Medical Records
• Appendix G - Written Notice Requirements
• Appendix H - Written Parent Consent Requirements

To:	Early Intervention Officials Approved Evaluators, Providers, and Service Coordinators Interested Parties
From:	Early Intervention Program
Date:	June 2003
Subject:	Guidance on Early Intervention Program Records

The New York State Department of Health, in its capacity as lead agency for the Early Intervention Program, is responsible for the general administration and supervision of municipalities and early intervention service providers, including the monitoring of all activities necessary to implement all requirements under the federal Individuals with Disabilities Education Act (IDEA) and Title II-A of Article 25 of New York State Public Health Law (PHL). Comprehensive early intervention records are necessary to document that requirements that apply to municipalities and early intervention service providers are met and to support payment for services by third party payors, localities, and the State. In addition, parents participating in the Early Intervention Program have the right to access and amend early intervention records pertaining to their child and family. Documentation should be up-to-date and readily available at any time for review by the parent and appropriate federal, state or local public agencies responsible for oversight of the EIP.

The purpose of this memorandum is to provide guidance regarding Early Intervention Program records. The memorandum summarizes requirements related to Early Intervention Program records under applicable State and federal laws and regulations. The memorandum also provides guidance on frequently asked questions related to Early Intervention Program records (referred to as "early intervention records" throughout this document).

Background

All municipalities and early intervention service providers¹ are subject to requirements pertaining to early intervention records in accordance with each of the following:

• Federal Family Educational Rights and Privacy Act (FERPA) and regulations (34 CFR Part 99) (see Appendix A).
• Individuals with Disabilities Education Act (IDEA) and regulations (34 CFR 303; 34 CFR 300.560 through 300 576)(see Appendix A).
• Title II-A of Article 25 of PHL and 10 NYCRR 69-4 Medical Assistance Program (Medicaid).

The Family Educational Rights and Privacy Act² (FERPA) is the federal law that protects the privacy of student education records. FERPA protections apply to student special education records under IDEA and to early intervention records under Part C of IDEA³. The State, municipalities, and early intervention providers must comply with the requirements contained in FERPA⁴. IDEA federal regulations at Section 300.560-300.576 relate to requirements under FERPA and also pertain to early intervention records.

There are no provisions in FERPA or IDEA that require the creation of a single, comprehensive child early intervention record. Rather, the federal laws and regulations contemplate that early intervention records pertaining to a given child and family will be created and maintained by public agencies and multiple early intervention providers with whom they interact. In addition, federal and state requirements recognize and account for the fact that some early intervention records will include information about more than one child and/or family.

FERPA and IDEA do give parents certain rights pertaining to their children's early intervention records (these rights extend through children and youths' educational experience and transfer to students when they reach 18 years of age or attend school beyond high school). These federal rights apply to early intervention records on:

• Evaluations and assessments.
• Eligibility determinations.
• Development and implementation of IFSPs.
• Individual complaints dealing with the child.
• Any other area under the Early Intervention Program involving records about the child and the child's family⁵.

The rights afforded to parents under FERPA and IDEA regulations at 34 CFR § 300.560-300.576 are incorporated in the Early Intervention Program regulations at 10 NYCRR 69-4.17 (c).

In addition, the Medicaid program also imposes certain requirements pertaining to child records. In New York State, all early intervention services are included in the State Medicaid Plan and are reimbursed by the Medicaid program for all children in the EIP who are also enrolled in the Medicaid program. All early intervention providers are required, as a condition of Department approval, to complete a Medicaid provider agreement and reassign benefits to the municipality⁶. Section 2557(3) of PHL designates municipalities as providers for the purpose of payment under Medicaid. As such, municipalities and providers are also required to comply with Medicaid Program regulations pertaining to records for children participating in the Early Intervention Program who are enrolled in Medicaid. The Medicaid Program regulations require that providers of service prepare and maintain contemporaneous records that demonstrate the provider's right to receive payment under the Medicaid program⁷. Because the Medicaid status of children is unknown to early intervention providers and to ensure consistent service delivery standards, all Medicaid requirements, including those pertaining to the content and retention of records, must be adhered to for all children receiving services under the Early Intervention Program.

Finally, several provisions in the public health law contain early intervention record requirements related to the documentation necessary for payment to providers and reimbursement of municipalities from third party payors (including Medicaid) and the State for services provided to eligible children. Section 2559 (3), for example, requires:

• municipalities to seek reimbursement in the first instance from third party payors, including the Medicaid Program, prior to seeking reimbursement from the State for the state share of costs associated with early intervention services; and,
• early intervention providers to submit adequate and complete information necessary to support municipal billing of third party payors, including the Medical Assistance Program.

In accordance with these requirements, municipalities and early intervention providers must maintain complete financial records and documentation necessary to support reimbursement from third party payors (including Medicaid) and the State; and, to permit a full fiscal audit by appropriate authorities. Municipalities are also responsible for verification of all payments made to early intervention providers and for auditing of claims in a manner consistent with other claims processed by the municipalities. Municipalities must have appropriate internal control and quality assurance procedures in this regard. It is recommended that municipalities include local requirements for billing, verification of payments, and auditing procedures in their contractual agreements with early intervention providers.

The following describes the general requirements and procedural safeguards under FERPA, IDEA, PHL, and the Medicaid Program that apply to early intervention records.

General Requirements for Early Intervention Program Records

Responsible Parties

As mentioned above, the federal laws and regulations contemplate that early intervention records pertaining to a given child and family will be created and maintained by municipalities and multiple early intervention providers with whom they interact. In New York State, the following parties are responsible for maintaining and protecting early intervention records in accordance with applicable federal and state laws and regulations:

• Municipal agencies responsible for local administration of the Early Intervention Program.
• Agency providers⁸ of early intervention services.
• Individual providers of early intervention services.

It is important to note that under circumstances where the municipality or agency provider delivers services through a subcontractor, the direct provider of service should retain the complete and original records related to the service(s) they deliver to the child/family. Original early intervention records generated by employees should be retained by the respective municipality or agency provider. All professionals must be aware of the standards that apply to their professions. Professionals are not released from these obligations for children who are receiving early intervention services under the Early Intervention Program.⁹

Content of Records

Applicable Definitions

New York State's Early Intervention Program regulations define "record" to mean "any information recorded in any way, maintained by an Early Intervention Official, designee, or approved evaluator, service provider or service coordinator. A record includes "any file, evaluation, report, study, letter, telegram, minutes of meetings, memorandum, summary, interoffice or intraoffice communication, memorandum reflecting an oral conversation, a handwritten or other note, chart, graph, data sheet, film, videotape, slide, sound recording, disc, tape and information stored in microfilm or microfiche or in computer readable form."^{10 11}

Programmatic Content

While there is no specific requirement to maintain comprehensive individual child/family records, it is recommended that documents pertaining to particular children (including session notes) be maintained in an individual child/family record. This type of record-keeping practice will assist municipalities and early intervention providers in meeting federal and state requirements regarding confidentiality of personally identifiable information, access to, and amendment of records;¹² and, will expedite programmatic monitoring and fiscal auditing procedures.

Municipalities must maintain early intervention records that document the performance of all activities required to be completed by Early Intervention Officials or their designees on behalf of eligible children and their families under Early Intervention Program regulations and public health law, including but not limited to: referral procedures; ensuring the performance of evaluation and assessments; development, review, and evaluation of IFSPs; ensuring the provision of services; and, due process procedures. See Appendix B for information expected to be found in municipal early intervention records. Early intervention records must clearly document dates of applicable events as needed to assess whether required timeframes are being met (e.g., date of referral, date of initial IFSP, etc.).

Early intervention providers must maintain records that document the performance of activities required to be completed by providers on behalf of eligible children and their families, including but not limited to: parental consents for provision of evaluations and early intervention services; reports, session notes, progress notes, and other documentation related to evaluations or service delivery; a copy of the IFSP; service authorizations; and, physicians orders and/or prescriptions for services provided. See Appendix C for information expected to be found in records maintained by early intervention providers.

Documentation Necessary for Billing and Claiming Purposes

As mentioned previously, the New York State Medicaid Program provides full coverage for all early intervention services delivered to eligible children who are also enrolled in Medicaid. Municipalities are required by PHL to claim insurance in the first instance for services delivered under the Early Intervention Program that are covered by a child's insurance plan. Early intervention providers are required by PHL to maintain documentation necessary to support municipal claiming to third party payors (Medicaid and commercial insurers) and the State.

It is important to distinguish between the documentation that should be included in early intervention records maintained by early intervention providers to establish the nature and extent of services delivered and progress being attained by the child and/or family and documentation that must be submitted to municipalities for billing and claiming purposes.

The following documentation is required for submission to municipalities by providers at the time payment is sought for services delivered to children under the Early Intervention Program in order to support claiming by the municipality to third party payors (i.e., Medicaid, commercial insurance and the State):

• Recipient identification (name, sex, age).
• Unit of service (e.g., home and community/facility-based, etc.) and specific type of service provided.
• Date(s) service was rendered.
• ICD-9 diagnostic code for the conditions or reasons for which care is provided.
• If an approved individual provider under direct contract with the municipality delivered the service, the name, address and license number of that professional.
• If an employee or subcontractor of an approved agency under contract with the municipality delivered the service, the name and identifying information of the early intervention provider billing the municipality for services should be submitted at a minimum.

The following information will also be required to be submitted at the time of billing to assist municipalities in securing reimbursement for early intervention services from providers:

• CPT code for delivered services.
• For agency providers, the name and license number of the employee or subcontractor who directly delivered the service.

The Department monitoring and audit protocols may include review of bills submitted to municipalities on or after November 1, 2003, to ensure this information is included.

The following information about the specific details of service delivery (e.g., session notes and progress notes) must be recorded and maintained by early intervention providers to establish the nature and extent of services provided and available for programmatic monitoring and fiscal audit purposes:

• Name and license, certification, or registration number of the professional who directly delivered the diagnostic or treatment service.
• A copy of the Individualized Family Service Plan (IFSP).
• Authorization from the municipality to deliver the service.
• Written orders or recommendations from specific medical professionals when required for the services being provided.¹³

Session notes specifically document that the early intervention provider delivered certain diagnostic and/or treatment services to a child and/or caregiver on a particular date. Session notes also assist payors, parents, early intervention providers and municipalities in assessing the extent to which services are helping the child/family to achieve the goals contained in the IFSP. Session notes must be completed by all qualified personnel (i.e. special educator, physical therapist, social worker, etc.) delivering the early intervention services authorized in a family's IFSP for each service delivered and must include:

• Recipient(s)'(child/parent/caregiver) name.
• Date of service.
• Type of service provided.
• Duration (length) of session.
• Brief description (2-3 sentences) of the recipient's progress made by receiving the service during the session as related to outcome contained in the Individualized Family Service Plan (IFSP), and
• Name, title and signature of the person delivering the service and date the session note was created.

See Appendix D for an example of a session note.

It should be noted that the Individualized Family Service Plan (IFSP) must include the criteria and procedures that will be used to determine whether progress toward achieving outcomes is being made or if modifications or revisions of the outcomes or services are indicated.¹⁴ Periodic progress notes summarizing the effectiveness of the service and progress being made toward major outcomes/rehabilitation goals should be prepared by all early intervention providers, at a minimum, for six-month reviews and annual evaluations of the IFSP. It is recommended that periodic progress notes be completed every 90 days. If the IFSP team¹⁵ agrees that, due to the child's age, condition, intensity of services being received, or other factors that more frequent progress notes are warranted (e.g., monthly), the specific timeframes for progress notes should be included in the IFSP.

Service Coordination Logs

Initial and ongoing service coordination responsibilities are detailed in Sections 69-4.6 and 4.7 of EIP regulations, as well as 10 NYCRR, Sections 4.17(e)(3(i); 4.17(g)(13)(iv); 4.17(h)(2)(ii)(a); 4.17(h)(7)(xvi) and Sections 4.20(b)(2) and 4.20(c); and Section 4.22(b)(1).

Service coordinators should document all activities related to the performance of their duties as required in Early Intervention Program regulations. Service coordination notes should fully describe the nature and extent of service coordination services provided, including the following information:

• Date of service.
• Description and time spent to accomplish service coordination activities.¹⁶
• Name and signature of the Service Coordinator, with the title "Initial Service Coordinator or Ongoing Service Coordinator" included as appropriate.

Coordination, Location, and Organization of Records Pertaining to Individual Children

It is recommended that providers and municipalities coordinate their record-keeping systems to ensure that required documents are physically located at the appropriate provider site in accordance with education law governing the professions or the municipal office to keep duplicate records at a minimum. Contractual agreements between municipalities and early intervention providers, and between agency providers and individual early intervention providers should include specific provisions on early intervention records to ensure that all federal and state requirements pertaining to these records are met. Periodic municipal review of provider early intervention records is recommended and should occur whenever possible at the provider site to avoid copying expenses and to minimize interruption of service delivery.

It is strongly recommended that municipalities and providers organize children's early intervention records in the chronological order in which events occur for programmatic monitoring and fiscal audit purposes.

It is recommended that municipalities and early intervention providers utilize a list or form to track significant dates and events as the child/family progresses through the early intervention system. The list/form should include relevant information for either the record maintained by the municipality, or the record maintained by a provider related to the service(s) provided. It is recommended that the list/form be located at the front of the child/family record for ease of access by providers, parents, municipalities and federal, state and local auditors.

Appendix E is a tool offered to municipalities and early intervention providers to assist them to organize children's early intervention records and track the accomplishment of required milestones. Appendix E includes a chronological list of all administrative milestones a child/family may achieve during their participation in the Early Intervention Program. All or some of these milestones may be applicable for a given child/family.

Use of Electronic Records and Signatures

The use of electronic records, including electronic signatures, is permissible under Federal Electronic Signatures in Global and National Commerce Act and Article 1 of the State Technology Law.

For Medicaid audit purposes, electronic documentation must be maintained in such a manner that Medicaid audit staff can answer basic questions to determine whether the requirement to prepare and maintain contemporaneous records that demonstrate the provider's right to receive payment under the Medicaid program has been met.¹⁷ These questions include:

• Does the record itself meet the general and specific requirements of the regulations as to content?
• Is it possible to determine when the record was created?
• Is there a process to prevent records from being altered after they are created?
• If records can be altered, is the alteration process documented?
• Is the actual caregiver identified in the record?
• If entries are menu driven, are they appropriate to the service provided and is the caregiver identified as having selected the entry?
• Has the provider set up a system of internal controls that insures that actual completed service delivery drives Medicaid billing?
• Are the records accessible? Records should be maintained in the ordinary course of business so that no "special" programming, software, language, etc., is required to access them.

In general, if a municipality or early intervention provider is able to answer these questions about their record keeping system positively, the system would meet the requirements for review of Medicaid billings being conducted by the Department's Office of Medicaid Management. Scanned documents, when consistent with the above requirements, are also generally acceptable for Medicaid record-keeping purposes.

For purposes of commercial insurance billing, if a municipality has the ability to directly bill commercial insurers electronically, records must be maintained electronically in the KIDS system (e.g., electronic records of transmittals that can be printed if necessary for audit purposes). If the municipality maintains a billing service to pursue reimbursement from third party plans, there must be an electronic record of the documents transmitted to the billing service. When billing third party payors, billing services must maintain records, either hard copy or electronic, that meet the requirements described above.

It should be noted that HIPAA requirements, when effective, will require that claims submitted electronically must be submitted in accordance with HIPAA standards.

Procedural Safeguards Pertaining to Early Intervention Records

Requirements relating to confidentiality/disclosure, access to records, and amendment of records contained in the Early Intervention Program regulations at 10 NYCRR § 69-4.17 (c)-(e) under the heading Procedural Safeguards. The program regulations require each municipality and all early intervention providers to adopt procedures that meet the requirements in 34 CFR Part 99 (FERPA) and sections 34 CFR sections 300.560 through 300.576, with modifications specified in 34 CFR 303.5(b) to preserve the confidentiality of records on eligible children participating in the Early Intervention Program.

The following summarizes the obligations of Early Intervention Officials and early intervention providers specified in 10 NYCRR § 69-4.17 (c) – (e) related to confidentiality, access to and amendment of early intervention records:

Confidentiality

Early Intervention Officials, early intervention providers (including individuals who are self-employed and under contract), and all personnel involved in mediation and impartial hearing procedures are responsible for ensuring the confidentiality of all personally identifiable information in all early intervention records.^{19 20}

Municipalities and early intervention providers, including individual early intervention providers with home offices, must have and implement appropriate procedures to ensure the confidentiality of personally identifiable information and to document access to children's early intervention records in accordance with these requirements. At a minimum, the municipality and early intervention providers must:

• Have a designated individual responsible for ensuring the confidentiality of personally identifiable information in children's early intervention records (in the case of self-employed early intervention providers, that early intervention provider is responsible for this function).
• Ensure that all early intervention records containing personally identifiable information are maintained in secure locations (e.g., in locked file cabinets). Early intervention providers who travel to a variety of locations to deliver services must ensure the security and confidentiality of early intervention records that are off-site (e.g., early intervention records in a car must be in a secure brief case, file, etc.).
• Ensure that when early intervention records contain information about multiple children, a parent who requests access to his/her child's record only receives the record(s) pertaining to that child/family.
• Maintain a record of any individual who accesses children's early intervention records and the purpose for which the record was accessed (with the exception of the parent, employees of the municipality, early intervention providers, or Department staff or designees).
• Assure that all employees, contractors, consultants, and volunteers are informed about and are required to adhere to the confidentiality policies and procedures.
• Adhere to all legal requirements that protect early intervention records containing sensitive information (such as sexual or physical abuse, HIV status, treatment for mental illness, the child's parentage, etc.).
• Ensure the confidentiality of all information maintained in an electronic format.

Early Intervention Officials are further required to:^{21 22}

• Establish policies and procedures that provide for the confidential exchange of information among parents and early intervention providers and state and municipal agencies.
• Make reasonable efforts to notify parents when maintenance of personally identifiable information is no longer needed for purposes of the Early Intervention Program.
• At the request of the parent, ensure that all personally identifiable information is removed from early intervention records and destroyed once the information is no longer needed for the Early Intervention Program. However, a permanent record of the child and family's name and address and the types and dates of services received may be maintained without time limitation.

Access to Records^{23 24}

Disclosure

According to federal and state law, parental consent must be obtained before personally

identifiable information is disclosed to anyone other than officials of participating agencies collecting or using the information for the purposes of the Early Intervention Program. In their oversight and monitoring capacity, employees of the New York State Department of Health, other state early intervention agencies, and municipalities may access any record pertaining to a child and the child's family that are collected, maintained, or used for the purposes of the Early Intervention Program.

The release of personally identifiable information and early intervention record content to any other individuals or departments/units within a municipality or provider agency who are not directly involved in the delivery or oversight of services to the child/family requires parental consent. A parent must give written permission to allow information in any early intervention record pertaining to their child to be released at any time, whether the child/family is currently participating in the EIP or not.

There may be instances when individuals other than the parent, approved evaluator, service provider, service coordinator or authorized federal, state and municipal employee currently directly involved with the child have authorization to access a child's record. In these instances, Early Intervention Officials, evaluators, service providers and service coordinators must record the name of the individual accessing the record, how authorized, the date of access and the purpose for which the party is authorized to use the record.

Consent for Exchange of Information

Under Early Intervention Program regulations,²⁵ Early Intervention Officials must provide for the confidential exchange of information among parents, evaluators, service providers and service coordinators and have policies and procedures in place for a parent to voluntarily give written consent for release of information. Early Intervention Officials must:

• Inform parents of the right to refuse a general release for disclosure of information.
• Offer parents the opportunity to sign selective releases that specify by name or category those individuals to whom information may be disclosed or from whom it is sought.
• Provide parents with the ability to revoke a general release at any time and include a statement to this effect on any general release forms used.

It is important for parents to be informed about the scope of information included in early intervention records that may be shared when they are asked to sign a consent. When parents sign a selective consent they can specify limitations to the release of information, including:

• Who can access information in their child's early intervention records.
• What information in their child's early intervention record can be released and to whom.
• Time period for which the consent to release information is applicable.

If parents are asked to sign a general consent, it is important for them to be informed and understand that they may allow information in the record to be shared at any time with all early intervention providers involved in providing services to the child and family and possibly to other parties.

Sensitive Information/Information Extraneous to Early Intervention

It is also important to recognize that there may be sensitive or extraneous information in children's early intervention records that does not directly relate to the Early Intervention Program. Early Intervention Officials and early intervention providers are responsible for being aware of and adhering to other confidentiality requirements that may apply to information included in children's early intervention records.

When disclosing or re-disclosing any information, the Early Intervention Official or early intervention provider must review the information to determine whether disclosure is necessary for the provision of early intervention services to the child and/or family by the receiving party. For example, an IFSP is appropriate to share, while a physician's report or social service report may not be necessary or appropriate to share with other early intervention providers.

Medicaid Information

Special rules apply to the disclosure of information relating to children who are enrolled in the Medicaid Program. Under NYS Social Services Law, "Information relating to persons applying for or receiving [Medicaid] shall be considered confidential and shall not be disclosed to persons or agencies other than those considered entitled to such information … when such disclosure is necessary for the proper administration of public assistance programs"²⁶ [Section 367-b(4)]. If questions arise whether documents containing Medicaid-identifying information may be released, including to another unit of the municipality or agency, please contact the NYS Department of Health's Division of Legal Affairs, Bureau of Medicaid Law at 518-408-1495.

Parental Access to Their Children's Records

Early Intervention Officials and early intervention providers are required to ensure parents are afforded the opportunity to inspect and review all records pertaining to the child and the child's family that are maintained or used for the purposes of the Early Intervention Program (unless the parent is prohibited such access under State or federal law). It should be presumed that the parent has the authority to inspect and review early intervention records pertaining to his or her child unless the Early Intervention Official or early intervention service provider has been advised otherwise under applicable State law and regulations related to guardianship and custody. If a record contains information on more than one child or on non-participants, only the portion of the record pertaining to the child's participation in the EIP may be accessed.

The opportunity for parents to review and inspect early intervention records includes the right to:

• Receive an understandable explanation about and interpretations of information included in any early intervention record upon request.
• Obtain a copy of any early intervention record within 10 working days of receipt of the request by the Early Intervention Official or early intervention service provider.
• Obtain a copy of any early intervention record within 5 days if the request is made as part of a mediation or impartial hearing.
• Have a representative review the record on the parent's behalf.

All of the above rights extend to the commissioner of social services for children in the care and custody or custody and guardianship of the local social services districts.

Early Intervention Officials and early intervention providers have the following authority and responsibilities related to assuring parental access to records:

• A reasonable fee may be charged to copy early intervention records upon parent request (not to exceed 10 cents per page for the first copy and 25 cents per page for additional copies), as long as the fee does not prevent the parent from inspecting and reviewing the record. No fees may be charged for records related to evaluations and assessments to which parents are specifically entitled (e.g., evaluation and assessment reports under 10 NYCRR § 69-4.8) unless specifically permitted under PHL § 18.²⁷
• Parents may not be charged fees for the search and retrieval of early intervention records. Information about individual children/families included in any early intervention record should be able to be produced as a separate record, or with the names and identifying information of other children/families redacted (removed) from the documentation before it is shared with the parent.
• A record of all parties obtaining access to records gathered, maintained, or used for the purposes of the Early Intervention Program (except by parents and employees) must be maintained and must include the name of the party, date access was given, and the purpose for which the record was accessed.²⁸

Requirements When Early Intervention Providers Also Operate Other Programs

When a provider operates other programs in addition to an approved early intervention program that follow other documentation and/or confidentiality requirements, early intervention records are subject to and must meet the requirements of all applicable early intervention-related federal and state laws and regulations. Under these circumstances, early intervention records must be maintained as distinct or removable from non-early intervention records. It is the responsibility of the provider to ensure the confidentiality of information regarding eligible children they are serving and non-participants.

Requirements for Children In Foster Care

For children in the care and custody or custody and guardianship of the local social services district, the local Commissioner of Social Services/designee has the right to access the records collected, maintained or used for the purposes of the Early Intervention Program. Although in general, information regarding a child in foster care is confidential, there are certain exceptions regarding disclosure of information relating to service plans and visitation. The Early Intervention Program must conform, to the extent appropriate, with existing law, regulations, standards and procedures unless information such as the name and address of the foster parent needs to be maintained in a confidential manner to protect the safety of the child.

When in doubt as to whether someone should be given access to a child's early intervention record, early intervention providers should consult with their Early Intervention Official and/or the local Commissioner of Social Services, and the municipality's attorney(s), to verify which information may be disclosed.

Amending the Record

IDEA and FERPA^{29 30} give the parent the right to request an amendment to any early intervention record pertaining to their child when the parent believes the information contained in the record is inaccurate, misleading, or violates the privacy or any other rights of the child.

Early Intervention Officials and early intervention providers are responsible for ensuring parents have the right to present objections and request amendments to the contents of records. Early Intervention Officials and early intervention providers are responsible for informing parents about the procedures to be followed to request an amendment to early intervention records pertaining to their child and maintained by that Early Intervention Official or provider.

If a parent requests an amendment to his/her child's record, the Early Intervention Official or early intervention provider must respond to the parent's request within 10 working days. If the Early Intervention Official or provider agrees to the amendment requested by the parent, s/he must notify the parent and the service coordinator of the agreement to amend the record.

If an early intervention provider does not agree to a parent's request to amend the record, s/he must notify the Early Intervention Official of that decision. Early Intervention Officials are responsible for notifying parents in writing if a request to amend the record is not agreed to by either the Early Intervention Official or an early intervention service provider. In addition, the Early Intervention Official is responsible for:

• Informing the parent of the right to an administrative hearing with regard to a requested amendment that has not been agreed to by the Early Intervention Official or an early intervention service provider.
• Convening an administrative hearing to amend the record within a reasonable time after receiving a request from a parent for such a hearing.
• Adhering to requirements in Early Intervention Program regulations for the conduct of the hearing.³¹
• Ordering any amendment the municipality determines to be appropriate to be made to the early intervention record in question; notifying all appropriate parties of the ordered amendment (including individuals who have a copy); and, notifying the parent when the record has been amended.
• Notifying parents when a requested amendment is not ordered, and informing parents of the right to include a statement in the record to be disclosed with the record reflective of their views; and, notifying the parent that the parental statement will be incorporated and disseminated as part of the record.

Service coordinators are responsible for:

• Ensuring the contents of the record are amended as requested when the Early Intervention Official or early intervention service provider agrees to the amendment (including copies of the record maintained at different locations and different parts of the record which include the information to be amended).
• Notifying the parent in his or her dominant language that a requested amendment has been made in writing or through a verbal explanation (unless it is clearly not feasible to do so).

Retention of Records

At a minimum, early intervention records must be retained by all municipalities and early intervention providers for six years from the date that care, services, or supplies were provided to the child and family to assure compliance with Medicaid Program requirements.

In addition, individual early intervention providers³² who are licensed, registered, or certified under state education law must retain records in accordance with the laws and regulations that apply to their profession. All professionals must be aware of the standards that apply to their professions. Professionals are not released from these obligations for children who are receiving early intervention services under the Early Intervention Program.³³

Municipalities, with the exception of any city with a population of one million or more, are subject to the Local Government Records law. Early intervention records are not exempt from the requirements under this law. The State Archives Records Administration (SARA), which implements the local government records law, has established the following record retention requirement for municipal early intervention records:

17.[884]

a. Individual case record:

b. Screening, assessment and referral records, not found in individual case record:

New York City is not subject to the Local Government Records Act. New York City public agencies are subject to the record keeping requirements of the New York City Department of Records and Information Services (DORIS). To date, no record-keeping requirements for early intervention records in addition to what is already established under FERPA, IDEA, PHL and Medicaid program requirements have been issued.

After the municipality determines child information is no longer needed, a permanent record consisting of the child's name, address, phone number and attendance record may be maintained without time limitation. The municipality must inform parents when personally identifiable information collected, maintained or used in the Early Intervention Program is no longer needed and the record may then be destroyed at the request of the parent.³⁴ It is recommended that parents be reminded that the records may be needed by the child or parent for future purposes, such as Social Security benefits.

Questions and Answers

1. Neither physician nor parent notes are required for absences. However, the child's early intervention record(s) and/or a group attendance log should document when a child receives or does not receive a service session (whether delivered at home, in the community, or at an early intervention provider site) on a particular day. Early intervention records should document who reported the child's absence or interrupted visit; who picked up the child if a service session was interrupted and the parent did not accompany the child; and, reason for absence if known. Documentation should be sufficient to ensure child safety and indicate whether or not a child received scheduled services on a given day.

   The parent, service coordinator, Early Intervention Official, service providers, and other participants in the development, review, and annual evaluations of the IFSP should reach agreement as to how missed visits will be addressed (for example, whether missed visits must be provided within a specified timeframe). This agreement should be documented in the IFSP.

2. There is nothing in state law or regulation that prohibits a municipality from establishing a policy that requires early intervention providers to obtain the signature of a parent or designated caregiver to document that home and community-based services have been delivered.

   If municipalities establish such a policy, the municipal contract with all early intervention providers should specify this requirement. In addition, the Early Intervention Official should inform parents about this policy, reasons for the policy, and expectations for parents and early intervention providers in adhering to this policy.

3. It is recommended that early intervention providers review their session notes on a regular basis with the child's parent and/or other caregivers involved in early intervention services. Ideally, session notes should be reviewed at the end of each visit or at the next session with the child in which the parent participates. For group developmental sessions, it is recommended that periodic progress notes be provided to parents every 90 days.

4. Parental consent is not necessary if the qualified personnel are directly employed by the same municipality or early intervention provider designated in the IFSP to deliver the child's service(s).

   Parental consent is necessary to share evaluations, progress notes, and any other information contained in early intervention records among individual contractors, consultants, volunteers, other early intervention providers and other parties (e.g., medical providers, child care providers, extended family members, etc.).

5. Early Intervention Program regulations require that written notice regarding certain actions must be sent to the parent or other individuals as the child/family progresses through the program. Regulations contain the specific information that must be included in these written notices. Appendix G to this memorandum is a chart that describes when notice must be sent, to whom, by whom, and the regulatory citation where information regarding the content of the notice can be found.

6. Early Intervention Program regulations require that written informed consent must be obtained from the parent at certain times during the child/family's progress through the program.

   Informed consent³⁵ means that:

   • The parent has been fully informed of all information relevant to the activity for which consent is sought, in the parent's dominant language or other mode of communication.
   • The parent understands and agrees in writing to the carrying out of the activity for which consent is sought.
   • The consent describes the activity and lists the records, if any, that will be released and to whom; and the parent understands that the granting of consent is voluntary on the part of the parent and may be revoked at any time.

   Appendix H to this memorandum is a chart that describes when consent must be obtained from the parent and by whom, including the regulatory citation where information regarding the content of the consent can be found.

7. State law is silent on this issue; however, when a physician issues a referral for an early intervention service, it is recommended that the treating therapist (licensed/certified professional) maintain the original referral as part of the provider record.

8. The physician's order or recommendation should be consistent with the frequency and time period during which the services are to be delivered as specified in the IFSP. New physician's orders or recommendations should be obtained any time there is a change in the period for which a service is to be delivered or a new service requiring an order or recommendation is added to the IFSP.

9. In some municipalities, individuals serve in multiple roles related to the Early Intervention Program (e.g., an individual may act both in the capacity of service coordinator and authorized county Early Intervention Official (EIO) or EIO Designee (EIO/D); an evaluator and initial service coordinator; or, as an early intervention provider and ongoing service coordinator).

   Under these circumstances, the person serving in multiple roles should perform all activities required by the EIP, document their activities in the early intervention record, and sign for each activity performed using the unique title associated with the activity being performed. For example, on the occasion where an individual performs dual responsibilities of both service coordinator and EIO or EIO/D, the record should reflect the activities/decisions made as service coordinator and as EIO or EIO/D. The individual may either sign the record twice (once using the title "Service Coordinator" and once using the title "EIO" or "EIO/D"), or sign once but indicate both titles, thus attesting to the activities (s)he performed in each role. In either case, the time spent on each activity should be clearly documented and available for state and local reviewers and auditors.

   Any individual serving in multiple roles must inform parents and other IFSP meeting participants when (s)he is taking action in each capacity.

10. No. Signature stamps do not demonstrate that the professional saw and agreed with the file and are not acceptable under Medicaid for reimbursement purposes.

11. Professionals who would like more information about record keeping requirements that apply specifically to their profession should contact the New York State Education Department, Office of the Professions, at (518) 474-3871 or visit the State Education Department's Web site (www.nysed.gov).

12. It is recommended that parents submit a written request to the relevant provider and/or their Early Intervention Official to access and review an early intervention record or records pertaining to their child. This request should specify whether a copy of the record is being requested or whether the parent wishes to review or inspect the original records with the Early Intervention Official or early intervention provider. The early intervention provider and/or Early Intervention Official is responsible for responding to and making arrangements for the parent to review and inspect the record(s). If a copy of the record is requested by the parent, the Early Intervention Official or early intervention provider may charge a reasonable fee for the copy, not to exceed 10 cents per page for the first copy and 25 cents per page for any additional copy, unless the fee prevents the parent from exercising the right to review and inspect the record. Parents cannot be charged a fee to obtain copies of evaluation or assessment documents, except where allowed under Section 18 of Public Health Law.

13. Parents should submit a request in writing to the Early Intervention Official or relevant early intervention provider (whichever party maintains the record to be amended) to amend any early intervention record pertaining to their child and/or family which they believe to be inaccurate, misleading, or in violation of the privacy or other rights of the child.

    The Early Intervention Official or early intervention provider is responsible for responding to the parent within 10 days of receipt of the request.

    If the Early Intervention Official or early intervention provider does not agree to the request to amend the record, the Early Intervention Official must notify the parent and the parent may request an administrative hearing from the Early Intervention Official.

    In the event that an administrative hearing is held, and the Early Intervention Official determines that a record should not be amended, s/he is responsible for notifying the parent of this decision. The parent may then include a statement in his/her child's record that must be disclosed any time the relevant part of the record is disclosed.

14. The service coordinator is responsible for ensuring that an agreed-upon amendment is made to every applicable record pertaining to the child. The service coordinator is responsible for notifying the parent in her/his dominant language when amendments to all applicable records have been completed.

15. Parents may request this information of their Early Intervention Official and any early intervention provider delivering services to their child. Early Intervention Officials and providers are responsible for providing parents with the right to inspect and review record and for maintaining a log of any individual who has accessed a child's record.

16. Complaints of alleged violations of Early Intervention Program regulations should be submitted to:
    Director, Early Intervention Program
    New York State Department of Health
    Room 287 Corning Tower Building
    Albany, New York 12237-0618

    Complaints of alleged violations of FERPA requirements may be addressed to:

    Family Policy Compliance Office
    U.S. Department of Education
    400 Maryland Avenue, SW
    Washington, D.C. 20202-4605

    Complaints to the Federal Policy Compliance Office must be submitted not later than 180 days from the date the individual submitting the complaint first learned of the circumstances of the alleged violation. Complaints should contain specific allegations of fact giving reasonable cause to believe a violation has occurred, including relevant dates; names and titles of those involved; a specific description of the record around which the alleged violation occurred; a description of contact with any officials regarding the matter; and any additional evidence that would be helpful.

    New York State Department of Health
    Early Intervention Program
    Room 287 Corning Tower Building
    Empire State Plaza, Albany, NY 12237-0618
    (518) 473-7016
    beipub@health.ny.gov

Appendix A - Summary of FERPA Requirements

The following is a summary of relevant requirements under Code of Federal Rules, Part 300 (Sections 300.560 through 300.576 with modifications specified in section 303.5(b) of Title 34 of the Code of Federal Regulations, and Part 303 of Title 34 of the Code of Federal Regulations):

Access to Early Intervention Records³⁶

Parents must be afforded the opportunity to:

• Inspect and review his or her child's early intervention records.
• Obtain copies of early intervention records upon request.

Amendment of Early Intervention Records³⁷

Parents must be afforded the opportunity to:

• Request that their child's early intervention records be amended if a record contains misleading or inaccurate information about the child or family.
• Obtain a hearing if a municipality or early intervention provider refused to amend a record.
• Include a statement to be kept and disclosed with the record if the record is not amended as the result of a hearing.

Confidentiality/Disclosure of Early Intervention Records³⁸

Parents must:

• Provide consent prior to the disclosure of early intervention records pertaining to their child, except under certain specified circumstances. The consent must be signed and dated and provide the purpose for the disclosure.

FERPA and IDEA also place certain requirements upon state lead agencies, public agencies/officials, and early intervention providers related to the confidentiality of information in children's early intervention records; parent access to records; and, amendment of children's early intervention records. These requirements include:

Notice to Parents³⁹

Municipalities must provide annual notification to parents as specified below:

• Notification to parents about their rights to inspect and review their children's early intervention records.
• Notification to parents about their rights to amend their children's early intervention records (including who to contact to amend a record(s)).
• Notification to parents about consent requirements for disclosure of personally identifiable information in their children's early intervention records.
• Information about how to file a complaint with the Family Policy Compliance Office.

Amendment of Early Intervention Records⁴⁰

• Procedures to consider a request from a parent to amend inaccurate or misleading information in a child's early intervention records.
• Procedures to offer a parent a hearing when an amendment to a record is refused.⁴¹
• Procedures to incorporate a statement from the parent if a record is not amended to be disclosed with the record.⁴²

Fees⁴⁴

• Fees may be charged for copies of records that are made for parents as long as the fee does not prevent the parent from exercising their rights to inspect and review early intervention records.
• Fees may not be charged to parents to search for or to retrieve information.

Record of Access

• Procedures to maintain a record of all parties obtaining access to early intervention records collected, maintained, or used under Part C (except access by parents or authorized employees), including the name of the party, the date access was given, and the purpose for which the party is authorized to use the records.⁴⁵

Disclosure of Records⁴⁶

• Procedures to obtain parent consent prior to disclosure of personally identifiable information.
• Procedures to ensure that the consent is signed and dated and states the purpose of the disclosure.
• Early intervention records MAY be disclosed without parent consent under the following circumstances:
• The disclosure is to state or local authorities auditing or evaluating Federal or State-supported Early Intervention Programs or enforcing federal laws pertaining to such programs.
• The disclosure is pursuant to a lawfully issued court order or subpoena.

Records on More Than One Child⁴⁷

• Procedures to ensure that if any early intervention record includes information on more than one child, the parents of those children have the right to inspect and review only the information relating to their child or to be informed of that specific information.

Lists of Types and Locations of Information⁴⁸

• Provision to parents, upon request, of a list of the types and locations of early intervention records collected, maintained, or used.

Safeguards⁴⁹

• Protection of the confidentiality of personally identifiable information at collection, storage, disclosure, and destruction stages.
• Designation of one official to assume responsibility for confidentiality of any personally identifiable information.
• Participation in training regarding requirements under FERPA.
• Maintenance, for public inspection, of a current listing of the names and positions of employees who may have access to personally identifiable information.

Destruction of Information⁵⁰

• Notification to parents by the public agency when personally identifiable information collected, maintained, or used for the purposes of the Early Intervention Program is no longer needed to provide early intervention services to the child.
• Destruction of personally identifiable information at the request of the parent (with the exception of certain information pertaining to service provision).

Enforcement⁵¹

• The State Lead Agency must have policies and procedures, including sanctions, that will be used to ensure that its policies and procedures related to early intervention records are followed and that federal requirements are met.

Disciplinary Information⁵²

• The State may require that a public agency include in the records of a child a statement of any disciplinary actions taken against the child. No such State requirement currently exists pertaining to the Early Intervention Program.

Appendix B - Examples of Documents Generated by Municipalities

The following exemplifies documents that meet the definition of "record" in Early Intervention Program (EIP) federal and state regulations that would typically be created and maintained by municipalities in their capacity as local administrators of the program. Municipalities must retain documentation demonstrating that all required administrative milestones and timelines under the Early Intervention Program were met for each individual child and family. The municipal administrative record will include at a minimum:

• Intake/referral information, including the date the referral was received by the municipality.
• Information regarding Medicaid and private third party insurance, with documentation indicating the date this information was last updated.
• Documentation indicating which required written notice(s) was sent to the parent and date sent.
• Documentation indicating which consent forms were signed by the parent and date signed.
• Documentation indicating the designation (including date) of the initial service coordinator.
• Documentation indicating the designation of a surrogate parent when applicable, and the circumstances leading to such designation.
• Evaluation and diagnostic reports, including family assessments and any medical records and correspondence to/from primary care physician(s) that are part of the evaluation record and demonstrate ongoing physician involvement.
• IFSPs and related documentation, including amendments to IFSPs.
• Periodic progress notes/reports used at IFSP meetings.
• Written correspondence to/from the municipality regarding the child and family.
• Municipal staff notes recording any relevant discussions with parents, providers or others regarding the child and family.
• For children in care, documentation indicating the exchange of appropriate information with the Commissioner or designee of the local social services district.
• All due process records (e.g., amending the record, mediation, impartial hearing).
• Transition documents, to demonstrate that required transition activities occurred.
• Closure documentation and/or forms to demonstrate how and when the child left the EIP.
• Bills from providers and any other appropriate fiscal information necessary to support municipal claims to third party insurers and/or the State.

Appendix C - Examples of Documents Generated by Early Intervention Providers

The following are types of documents that meet the definition of "record" in Early Intervention Program (EIP) federal and state regulations that would typically be created and maintained by early intervention providers (including the municipality when the municipality is acting in the capacity of an approved provider):

• Written correspondence with or regarding the child/family.
• Notes recording any relevant discussions with parents, other providers, or municipalities regarding the child and family.
• Documentation of written notice(s) (if any) sent to the parent by the provider, including date of notice.
• Any signed and dated parental consents relevant to service delivery and/or disclosure of information.
• IFSPs and related documents, including IFSP amendments.
• Service authorizations.
• Additional documents may be included for providers of service coordination services.
• Documentation demonstrating the provision of services, including session/progress notes.
• Group attendance lists.
• Child/family reports, including evaluations (with relevant medical reports) and ongoing assessments related to the services provided.
• Closure documentation and/or forms to demonstrate how and when the child transitioned from the Early Intervention Program or completed or ended early intervention services for other reasons.
• Physicians orders and other prescriptions.
• Other appropriate fiscal information necessary to substantiate the early intervention claims to the municipality.

Appendix D - Sample Session Note

John continues to use more words spontaneously when engaged in play activities. Today he produced one, 3-word utterance ("I want more") and 7 single words spontaneously. He also imitated several 2-3 word utterances modeled during the session. John responded well to the kitchen-set; will use again to elicit additional spontaneous speech.

Jane Doe, CCC-SLP, __/__/____

(Signature and Date Note Was Completed)

Appendix E - Checklist for Early Intervention Records

This checklist is offered as a tool to municipalities and providers to assist them to organize a child/family record, and to track the accomplishment of required milestones. The checklist includes a chronological list of administrative milestones a child/family MAY achieve during their participation in the Early Intervention Program. All or some of these milestones may be applicable for a given child/family. The municipality and early intervention providers may utilize all or part of this checklist as one way to demonstrate that they have accomplished all required administrative milestones and timelines for a family. It is strongly recommended that municipalities and early intervention providers use this checklist or a modified version of the checklist in each child/family record, so that the content of records on the provider and municipal level demonstrate the records contain sufficient and appropriate information to withstand fiscal and/or programmatic audit and review.

Date(s) or	N/A	Event(s)	Regulatory Citation
__/__/__		Referral of child/family to the EIO/D	69-4.3(a)
__/__/__		EIO/D designates ISC	69-4.7(a)
__/__/__		EIO/D sends written notice of designation of ISC to parent	69-4.7(a)
__/__/__		EIO/D forwards parent handbook to parent	69-4.7(a)(1)
__/__/__	N/A	EIO/D notifies local commissioner of social services of designation of ISC	69-4.7(a)(2)
__/__/__	N/A	EIO/D obtains consent for the birth/adoptive parent to voluntarily appoint a surrogate parent	69-4.16(e)
__/__/__	N/A	EIO/D selects a qualified surrogate parent	69-4.16(d)
__/__/__		EIO/D provides parent with required info about their rights/entitlements	69-4.17(a)
__/__/__		ISC first contacts parent	69-4.7(b)
__/__/__		ISC provides parent with required information & assists parent to choose evaluator and access evaluation	69-4.7(b)-(p)
__/__/__		ISC provides EIO with information regarding Medicaid, CHP and/or private 3rd party insurance (updated at each IFSP meeting)	69-4.7(h)
__/__/__		EIO/D sends written notice of initial IFSP meeting to required participants	69-4.11(a)(5)
__/__/__		EIO/D sends written notice of subsequent IFSP meeting to required participants	69-4.11(a)(5)
__/__/__	N/A	Evaluator sends notice to EIO of parent selection prior to designation of ISC	69-4.8(a)(1)
__/__/__		Evaluator obtains consent for initial multidisciplinary evaluation to determine eligibility, to obtain the child's current health status and medical history, to interview other family members or individuals, to use findings from other current evaluations, and to send evaluation summary/report to primary health care provider.	69-4.8(a)(1)-(9)
__/__/__		Initial multidisciplinary evaluation to determine eligibility occurs	69-4.8(a)(2) – (9)
__/__/__	N/A	EIO/D authorizes a second evaluation or component	69-4.8(a)(10)
__/__/__	N/A	EIO/D obtains consent to obtain repeat or supplemental evaluations, additional evaluations/diagnostic tests occur (if appropriate)	69-4.8(a)(12)&(13)
__/__/__	N/A	EIO/D obtains consent to commence interim IFSP services	69-4.8(a)(12) 69-4.11(c)
__/__/__	N/A	EIO/D obtains consent to invite persons the parent wants to the IFSP meeting	69-4.11(a)(2)(v)
__/__/__		EIO/D sends written notice of initial IFSP meeting to required participants	69-4.11(a)(5)
__/__/__		Initial IFSP meeting occurs	69-4.11(a)(2)-(10)
__/__/__		EIO/D sends written notice(s) of subsequent IFSP meetings to required participants	69-4.11(a)(5)
__/__/__		Subsequent IFSP meetings occur	69-4.11(b)
__/__/__		SC amends IFSP(s)	69-4.6(b)(2) & 69-4.17(e)(3)(i)& 69-4.17(g)(13)(iv)& 69-4.17(h)(7)(xvi)
__/__/__		SC implements each service authorized in each IFSP	69-4.11(a)(10)(xii)& 69-4.11(c)
__/__/__		EIO/D sends notice to parent within 10 working days before proposing to initiate or change the identification, evaluation, service setting or provision of services to the child/family	69-4.17(b)(1)
__/__/__		EIO/D sends notice to parent regarding their due process rights	69-4.17(b)(2)
__/__/__		EIO/D obtains consent to release any information	69-4.17(c)(5)
__/__/__	N/A	Parents report problem(s)
__/__/__	N/A	Problems are resolved
__/__/__	N/A	Surrogate parent(s) are removed if necessary	69-4.16( i )
__/__/__	N/A	Parents request to review/correct/inspect their records	69-4.17(a)(5) & 69-4.17(d)
__/__/__		EIO/D sends notice to parent when personally identifiable information is no longer necessary for the program	69-4.17(c)(6)
__/__/__	N/A	Parent requests the record be amended and record is amended	69-4.17(e)(1)(2)&(3)
__/__/__	N/A	EIO/D sends notice to parent declining their request to amend the record and notice of the parent's right to an administrative hearing	69-4.17(e)(3)(ii)
__/__/__	N/A	EIO/D sends notice(s) of hearing to amend the record to the parent	69-4.17(e)(4)(ii)
__/__/__	N/A	Hearing (by municipality) to amend the record occurs	69-4.17(e)(4)
__/__/__	N/A	Parent requests mediation services	69-4.17(g)(4)
__/__/__	N/A	EIO/D sends notice to community dispute resolution center requesting a mediation	69-4.17
__/__/__	N/A	EIO/D informs the parent of nature of mediation services	69-4.17(g)(3)
__/__/__	N/A	EIO/D sends written request to parent to participate in mediation	69-4.17(g)(5)
__/__/__	N/A	EIO/D obtains parental consent to transmit personally identifiable information to the community dispute resolution center	69-4.17(g)(6)
__/__/__	N/A	Community dispute resolution center contacts EIO and parent to discuss mediation	69-4.17(g)(8)
__/__/__	N/A	Community dispute resolution center obtains parental consent to extend the timeline for mediation proceedings	69-4.17(g)(9)
__/__/__	N/A	Mediation occurs	69-4.17(g)(13)
__/__/__	N/A	Parent, EIO & SC receive a copy of mediation agreement	69-4.17(g)(13)(iii)
__/__/__	N/A	After unsuccessful mediation, EIO/D informs parent of the right to, and procedures for, impartial hearing	69-4.17(g)(13)(v)
__/__/__	N/A	Parent and respondents receive notice from NYSDOH when impartial hearing is requested	69-4.17(h)(2)(i)
__/__/__	N/A	Municipality sends notice to parent within 5 working days that the municipality intends to be represented by counsel	69-4.17(h)(2)(ii)
__/__/__	N/A	The parties involved in the dispute enter into an agreement to resolve the dispute	69-4.17(h)(7)(ix)
__/__/__	N/A	EIO/D stipulates to resolve the matters in dispute	69-4.17(h)(7)(ix)(a)
__/__/__	N/A	Impartial hearing occurs	69-4.17(h)(5)-(7)
__/__/__	N/A	Notice of written/oral decision is received by parties as stipulated	69-4.17(h)(7)(xv)
__/__/__	N/A	IFSP is modified within 5 working days after receipt of written or oral decision	69-4.17(7)(xvi)
__/__/__		EIO/D obtains consent to implement transition procedures	69-4.11(a)(10)(xiv)(d)
__/__/__		EIO/D obtains consent to provide written notification to the CPSE of the child's potential transition	69-4.20(b)
__/__/__		EIO/D obtains parent consent to transmit information to the CPSE	69-4.11(a)(10)(xiv)(d)
__/__/__		EIO/D obtains consent to convene a transition conference that includes the CPSE chairperson	69-4.20(b)(3)
__/__/__		EIO/D obtains consent to notify the CPSE that the parent of a child potentially eligible for preschool special education (4410) services has elected to continue with EI services for the specified period of eligibility under PHL Section 2541(8)	69-4.20(d)
__/__/__		SC obtains consent to incorporate the transition plan into the IFSP	69-4.20(a)(2)(iii)
__/__/__		SC obtains consent to transfer appropriate evaluations, assessments, IFSPs etc. during transition	69-4.20(b)(2)
__/__/__	N/A	EIO/D sends notice to local social services commissioner regarding potential transition of child to preschool special education (4410) services	69-4.20(b)(1)
__/__/__		Record closed

Appendix F - Medicaid Requirements for Medical Records

Under the Medicaid Program, in the case of bills for physician services, physicians are required to maintain complete, legible records in English for each child treated. Medical records shall include at a minimum, but not be limited to, the following:

• The full name, address and medical assistance program identification of each patient examined and/or treated in the office for which a bill is presented.
• The date of each patient visit.
• The patient's chief complaint or reason for each visit.
• The patient's pertinent medical history as appropriate to each visit, and findings obtained from any physical examination conducted that day.
• Any diagnostic impressions made for each visit.
• A recording of any progress of a patient, including patient response to treatment.
• A notation of all medication dispensed, administered or prescribed, with the precise dosage and drug regimen for each medication dispensed or prescribed.
• A description of any X-rays, laboratory tests, electrocardiograms or other diagnostic tests ordered or performed, and a notation of the results thereof.
• A notation as to any referral for consultation to another provider or practitioner, a statement as to the reason for, and the results of, such consultations.
• A statement as to whether or not the patient is expected to return for further treatment, the treatment planned, and the time frames for return appointments.
• A chart entry giving the medical necessity for any ancillary diagnostic procedure.
• All other books, records and other documents as are necessary to fully disclose the extent of the care, services, and supplies provided.

Appendix G - Written Notice Requirements

Notice	Responsible Party	Regulatory Citation
To the parent indicating designation of the initial service coordinator (ISC)	Early Intervention Official/designee (EIO/D)	69-4.7(a)
For children in care, to the local Commissioner of Social Services indicating designation of ISC	EIO/D	69-4.7(a)(2)
To EIO/D regarding the parent's eligibility for benefits from a health insurance policy or benefits plan	Initial Service Coordinator (ISC)	69-4.22(b)(1)
To insurance company regarding the parent's eligibility for benefits from a health insurance policy or benefits plan and intent to exercise subrogation rights	EIO/D	69-4.22(b)(1)
To EIO/D regarding parent selection of evaluator prior to designation of ISC	Parent or Evaluator	69-4.8(a)(1)
To the parent upon denial of eligibility	EIO/D	69-4.17(b)(2)(i)
To the parent and required participants regarding the initial IFSP meeting	EIO/D	69-4.11(a)(5)
To the parent and required participants regarding subsequent IFSP meetings	EIO/D	69-4.11(a)(5)
To the parent, 10 working days before EIO/D proposes or refuses to initiate or change the identification, evaluation, service setting, or provision of services	EIO/D	69-4.17(b)(1)

Appendix H - Written Parent Consent Requirements

Consent	Obtained By	Regulatory Citation
For the initial multidisciplinary evaluation and/or screening	Evaluator	69-4.8(a)(1)(ii)
To obtain the child's current health status and medical history	Evaluator	69-4.8(a)(4)(ii)
To interview other family members or individuals with pertinent knowledge of the child	Evaluator	69-4.8(a)(4)(iii)
To use findings from other current examinations, evaluations or assessments and health assessments	Evaluator	69-4.8(a)(5)
To send the evaluation summary/report to the child's primary health care provider	Evaluator	69-4.8(a)(9)(i)
To obtain repeat or supplemental evaluations	EIO/D	69-4.8(a)(12)
To commence interim services	EIO/D	69-4.11(c)(2)(i)
To invite other persons the parent wants to attend IFSP meetings	EIO/D	69-4.11(a)(2)(v)
To commence services listed in the IFSP	EIO/D	69-4.11(a)(8)
For the birth or adoptive parent to voluntarily appoint a surrogate parent	EIO/D	69-4.16(e)
To release any information	EIO/D	69-4.17(c)(5)
To transmit personally identifiable information to the Community Dispute Resolution Center if mediation is requested	EIO/D	69-4.17(g)(6)
To extend the timeline for mediation proceedings	Community Dispute Resolution Center	69-4.17(g)(9)
To incorporate the transition plan into the IFSP	OSC	69-4.20(a)(2)(iii)
To implement transition procedures	EIO/D	69-4.11(a)(10)(xiv)(c)
To transmit information to the CPSE	EIO/D	69-4.11(a)(10)(xiv)(d)
To provide written notification to CPSE of potential transition to preschool special education (4410) services	EIO/D	69-4.20(b)
To transfer appropriate evaluations, assessments, IFSPs, and other pertinent records during transition	OSC	69-4.20(b)(2)
To convene a transition conference that includes the chairperson of the CPSE to review program options and establish a transition plan	EIO/D	69-4.20(b)(3)
To notify the CPSE that the parent of a child potentially eligible for preschool special education (4410) services has elected to continue with EI services for the specified period of eligibility under PHL Sec. 2541(8)	EIO/D	69-4.20(d)

Footnotes

¹ Throughout this guidance document, the term "early intervention providers" will be used to refer to any individual, incorporated entity, sole proprietorship, partnership, or state-operated facility approved by the Department to deliver early intervention services (including evaluations, service coordination, and general services) and under contract with a municipality or under subcontract with another early intervention provider.
² 20 U.S.C. § 1232g
³ 34 CFR 303.5(a)(3)
⁴ 34 CFR 303.5(b)
⁵ 34 CFR 303.302
⁶ 10NYCRR § 69-4.5 (3)(a)(3)
⁷ Commercial insurance plans require similar documentation for payment purposes.
⁸ Incorporated entities, sole proprietorships, partnerships, and state operated facilities approved to deliver early intervention services and under contract with a municipality(ies).
⁹ Information on practice acts can be obtained from the New York State Education Department, Office of the Professions, at www.nysed.gov or (518) 474-3871.
¹⁰ 10 NYCRR § 69-4.1(kk)
¹¹ A hearing record under the Early Intervention Program, the contents of which would also be covered by FERPA, includes any notice, pleading, motion, evidence, question, offer of proof, objection, ruling, statement noticed by a hearing officer (administrative law judge), and any finding of fact, conclusion of law, decision, determination, opinion, order or report of the impartial hearing officer [10 NYCRR § 69-4.1(t)].
¹² See 10 NYCRR § 69-4.17(c)
¹³ Physical therapy services require a written order from a physician, physician's assistant, or nurse practitioner; occupational therapy services require a written order from a physician or nurse practitioner; and nursing services must have a written physician's order. A written recommendation from a physician, nurse practitioner, or speech language pathologist, resulting from the child's evaluation, is necessary for speech language pathology services.
¹⁴ 10 NYCRR § 69-4.11(10)(iv)
¹⁵ Parent, Early Intervention Official, service coordinator, early intervention providers, and others invited to participate in the IFSP meeting.
¹⁶ See the Early Intervention Memorandum 94-4, Reissued in 2000, on Service Coordination. Copies of this or any other guidance previously issued by the Department on the Early Intervention Program can be obtained by contacting the Program (Click here for contact information).
¹⁷ Commercial insurance plans require similar documentation for payment purposes.
¹⁸ 10 NYCRR § 69-4.17(c)(2)
¹⁹ 34 CFR § 300.571; 34 CFR § 99.30 - 38
²⁰ 10 NYCRR § 69-4.17(3)(c)
²¹ 10 NYCRR § 69-4.17 (4)(5)
²² 34 CFR § 99-30-38
²³ 10 NYCRR § 69-4.17(d)
²⁴ 34 CFR § 300.562
²⁵ 10 NYCRR § 69-4.17
²⁶ 18 NYCRR § 367-b(4)
²⁷ 34 CFR § 300.566
²⁸ 34 CFR § 300.563
²⁹ 10 NYCRR § 69-4.17 (e)(4)
³⁰ 34 CFR § 300.567
³¹ 10 NYCRR § 69-4.17(4)
³² Individual providers include individuals under contract with either a municipality or an approved agency provider (incorporated entity, sole proprietorship, partnership, or state operated facility) and those employed by a municipality or approved agency provider.
³³ Information on practice acts can be obtained from the New York State Education Department, Office of the Professions, at www.nysed.gov or (518) 474-3871.
³⁴ 10 NYCRR § 69-4.17 (c); 34 CFR §§ 300.573, 303.460
³⁵ 10 NYCRR § 69-4.1(x)(1)(2)(3) ³⁶ 34 CFR § 300.562
³⁷ 34 CFR § 300.576
³⁸ 34 CFR § 300.571; 34 CFR § 99.30 - 38
³⁹ 34 CFR § 99.7; 34 CFR § 300.561
⁴⁰ 34 CFR § 300.567
⁴¹ 34 CRF § 300.568
⁴² 34 CFR § 300.569
⁴³ 34 CFR § 300.566
⁴⁴ 34 CFR § 300.563
⁴⁵ 34 CFR § 300.563
⁴⁶ 34 CFR § 99.30-38
⁴⁷ 34 CFR § 300.564
⁴⁸ 34 CFR § 300.565
⁴⁹ 34 CFR § 300.572
⁵⁰ 34 CFR § 300.573
⁵¹ 34 CFR § 300.576
⁵² 34 CFR § 300.576