North Carolina Department of Health and Human Services
Division of Public Health
North Carolina Infant-Toddler Program
Prior Written Notice and
Consent for Evaluation and Assessment
Child’s Name:
Child’s Medical Record #
Date of Birth:
Reason for Prior Written Notice: This is to notify you that federal and state regulations require the North Carolina Infant-Toddler Program
to provide ten (10) days prior written notice to conduct evaluationand assessmentactivities. You may agree to have the proposed action(s)
occur sooner and not wait the ten (10) days.
Select the appropriate actions for which prior written notice is provided and consent is sought
ELIGIBILITY EVALUATION
Proposed Action:
CHILD ASSESSMENT
Proposed Action:
Initial Evaluation to determine eligibility OR
Evaluation after enrollment to determine ongoing eligibility
Initial Child Assessment
Action: Eligibility Evaluation
Action: Child Assessment
Reason: The purpose of evaluation is to determine your child’s
initial or ongoing eligibility for the NC Infant-Toddler Program (NC
ITP).
Reason: A child assessment for eligible children is conducted prior
to the initial development of the IFSP to inform intervention planning.
Consent for Eligibility Evaluation
Consent for Child Assessment
I have been fully informed of all information relevant to the
eligibility evaluation. I understand my consent is voluntary and may
be revoked in writing at any time. I understand that my child will not
receive the eligibility evaluation unless I give my written consent.
I have been fully informed of all information relevant to the child
assessment. I understand my consent is voluntary and may be
revoked in writing at any time. I understand that my child will not
receive the assessment unless I give my written consent.
_____ (initial) I give my consent for the NC ITP to carry out the
eligibility evaluation as described above.
_____ (initial) I give my consent for the NC ITP to carry out the
assessment as described above.
Consent to Bill Insurance / Medicaid
_____ (initial) I have received a copy of the NC ITP System of Payment Notification. The notifications related to billing private and
publicinsurance benefits have been explained to me and I understand them.
_____ (initial) I understand that evaluation, assessment and service coordination activities are provided at no cost to all families, regardless
of consent for billing private or public insurance benefits.
I Do
I Do Not give consent for the NC ITP and authorized service providers to bill the private insurance and / or public insurance
(Medicaid), on record for my child, for the Eligibility Evaluation and/or Child Assessment (and related service coordination activities as
applicable prior to initial IFSP development). I authorize the release of medical or clinical information necessary to process the insurance
claim. If my child is covered by private insurance and Medicaid, I understand that Medicaid policy is that private insurance must be billed
first, before Medicaid benefits can be accessed.
Parent Signature
Parental Notice of Child and Family Rights and Procedural Safeguards:
A copy of the North Carolina Infant-Toddler Program Notice of Child and
Family Rights document is provided to you and pertinent rights and
procedural safeguards are reviewed and explained as an accompaniment to
all prior written notice forms. This information includes all the procedural
safeguards that are available, including a description of mediation, due
process and state complaint procedures and the timelines for those
procedures.
Date
For CDSA Use(check and complete all that apply):
NC ITP 7053Consent for Eligibility Evaluation and Child Assessment (April 2013, Review 7/14)
Notice mailed on
Notice hand-delivered on
Parent agreed on
to have the proposed action(s) occur sooner and
not wait the ten (10) day prior notice time.
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North Carolina Department of Health and Human Services
Division of Public Health
North Carolina Infant-Toddler Program
Prior Written Notice and
Consent for Evaluation and Assessment
Purpose:
To obtain parent acknowledgement that the family has received written notification of their rights and that these
rights and procedural safeguards have been explained;
To obtain written parental consent for the evaluation to determine eligibility and/or assessment to assist with
intervention planning; and
To give prior written notice to the family for evaluation and assessment activities.
Instructions:
Enter child’s name and date of birth;
Consent for Action(s): Select the appropriate actions for which prior notice and consent is being sought and place a
check in the appropriate boxes. This can be evaluation and/or assessment. Be sure to direct the parent to initial one
or both places (evaluation and assessment) if appropriate.
Consent for billing:Consent to use a family’s insurance must be obtained prior to billing insurance for any early
intervention services; and each time consent for services is required due to an increase (in frequency, length,
duration, or intensity) in the provision of services in the child’s IFSP. Notification of child and family rights and
related financial policy using the NC ITP System of Payment Notification must occur whenever consent for the use
of insurance is requested.Parents should initial the line to confirm that they have received a written copy of the NC
ITP System of Payment Notification and that the notifications related to billing private and publicinsurance benefits
have been explained and they understand them. The EI Service Coordinator should review with the parent all
pertinent notifications, rights, and safeguards related to use of insurance benefits and consent for use of insurance.
When applicable, parents should initial the line to confirm they understand that when covered by private insurance
and Medicaid, that under Medicaid policy private insurance must be billed first, before Medicaid benefits can be
accessed.
Once all notification, rights, and safeguards have been explained, the parent, or parent surrogate, should use the
appropriate check boxes to indicate consent instructions for use of insurance including any exceptions.
For CDSA Use Box: Document the date the prior notice was mailed or hand-delivered to the parent. The family
should be given ten days prior notice unless they agree to have the evaluation occur sooner. The family must be
given a copy of the notice even if they agree to not wait the ten days.
File completed form in the child’s record. Mail or hand-deliver a copy of the notice to the parent.
Disposition:
Infant-Toddler Program records, including financial and automated information,must be maintained based upon the
Infant-Toddler Program’s record retention policy. Records must be archived in accordance with state requirements
to ensure their preservation for the required length of time.
NC ITP 7053 Consent for Eligibility Evaluation and/or Child Assessment(April 2013, Review 7/14)
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