Insurance Service Coordination Tool Kit

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NEW YORK STATE DEPARTMENT OF HEALTHBUREAU OF EARLY INTERVENTIONINSURANCETool Kit for Service CoordinatorsTool Kit Items:1.Initial Service Coordinator Insurance Responsibilities2.Ongoing Service Coordinator Insurance Responsibilities3.Collection of Insurance Information – Form A4.Child Insurance Information – Form B5.Authorization to Release Health Insurance Information – Form C6.Request for Coverage Information – Form D7.Instructions for Ongoing Service Coordinators: Collecting the Written Referral fromParents or Primary Health Care Practitioners8.Written Referral from Primary Health Care Practitioner – Form E9.Parent Notice Regarding Insurance10. ITEM 10 Form F- Has been removed- no longer applicable11. Required Notice of Subrogation – Sample12. Guidance on Billing Medicaid for Children enrolled in Medicaid Managed Care Plans13. Guidance on Entering Non-Regulated Insurance Plans in NYEISRevised October 2019

InsuranceTool Kit Item 1NEW YORK STATE DEPARTMENT OF HEALTHBUREAU OF EARLY INTERVENTIONInitial Service Coordinator Insurance Responsibilities1) Provide parent(s) with a copy of the Parent Notice Regarding Insurance (Tool Kit Item 9) and review thisinformation. Discuss with the family the requirements in New York State Public Health and InsuranceLaw:a. Under New York State Public Health Law (PHL), Early Intervention Program (EIP) services mustbe provided at no cost to parents [Section 2557 of PHL, 10 NYCRR Section 69-4.1(m)(1)(iv)(d)]b. Commercial Insurance and Medicaid are part of New York State’s system of payments for earlyintervention services. These third-party payors are important resources for the EIP (Section2559 of PHL)c. Insurance will only be accessed for reimbursement of early intervention services if the child’spolicy is subject to New York State Insurance Law (regulated). 10 NYCRR Section 69-4.22(a)i. EIP providers are required to first bill third-party insurance, including commercialinsurance and Medicaid, and are responsible for providing the subrogation notice (seeTool Kit Item 11)ii. Service coordinators are responsible for informing EI service providers that they canaccess information about the child’s insurance coverage in NYEIS and a copy of thecompleted Collection of Insurance Information form and the Child Insurance Informationform will be mailed to them if requested, within fourteen days of receipt of the requestiii. Providers will receive payment from municipal funds (escrow account) for services thatare partially reimbursed or denied by the insurer, if the provider claim has met all otherapplicable early intervention billing and claiming rulesiv. The Medicaid Program covers all EIP services at the EIP payment rates established bythe Statev. Providers are prohibited from seeking payment for EIP services from the parentd. Early Intervention Program (EIP) services must be provided to all eligible children in accordancewith the child’s Individualized Family Service Plan (IFSP), including service coordination andevaluations. This is inclusive of children that are uninsured.i. If a child is uninsured, the service coordinator is responsible for assisting the parent inidentifying and applying for benefit programs for which the family may be eligibleincluding Medicaid, Child Health Plus, and Social Security Disability Income; however,the parent is not required to enroll in order for EIP services to be provided.ii. Form B, Child Insurance Information form, includes a Parent Attestation of No Insurancesection. Parents must sign this attestation if their child does not have health insurancecoverage. Service coordinators must review a child’s insurance coverage informationwith the family on a quarterly basis or more frequently if the child’s insurance statusPage 1 of 5Revised October 2019

changes. A new attestation must be signed by the parent at each IFSP meeting, unlessthe child has obtained insurance coverage.iii. Upload Form B to the child’s integrated case in NYEIS. Notify all billing providers and theMunicipality that these completed forms are accessible on NYEIS and hard copies will bemailed to them within fourteen days of the receipt of a request.e. Protections for use of regulated insurance:i. Parents do not pay any out-of-pocket costs, such as deductibles or co-payments for EIPservicesii. Insurers are prohibited from charging any benefits paid for EIP services against anymaximum annual or lifetime policy limits ("caps")iii. Early Intervention visits reimbursed by the insurer cannot reduce the number of visitsotherwise available to the child and family for health careiv. Insurers cannot discontinue or fail to renew a child’s insurance coverage solely becausea child is receiving EIP servicesv. Insurers cannot increase health insurance premiums solely because a child is receivingEIP servicesvi. If a child’s insurance plan is not regulated by New York State Insurance Law, the plan willnot be billed for early intervention services. However, the non-regulated insurance planinformation must be recorded in NYEIS. See Took Kit Item 13 for detailed information.f.Non-regulated insurance: If a child’s insurance is not regulated by New York State InsuranceLaw, their insurance benefits may not be protected as set forth above in (e) if billed for EIPservices. Therefore, non-regulated insurance is not billed for EIP services.2) Collect insurance policy information from family (10 NYCRR 69-4.6(d)).a. Service Coordinators should give the family Form B (Child Insurance Information) and the forminstructions. Service Coordinators should review the instructions with the parents and assistthem with completing Form B (Child Insurance Information).b. Service Coordinators must obtain written parental consent on Form C (Authorization to ReleaseHealth Insurance Information).c. Explain to the parent that he or she should let their ongoing service coordinator know any timethere are changes in the child’s insurance policy, including Medicaid and Child Health Plus. Theservice coordinator must review the child’s insurance information with the family at leastquarterly and at any time a child’s insurance changes.d. Service coordinators need to document in their service coordination notes their discussion withthe parent regarding the child’s insurance coverage. If the service coordinator chooses to useForm A, the service coordinator can initial and date the form when they review a child’sinsurance information with the family.Page 2 of 5Revised October 2019

3) Determination of Insurance Plan Informationa. Determine if the child’s insurance plan is regulated by New York State Insurance Lawi. Contact the insurer directly to identify if the child’s plan is regulated List of things to know before callingo Product- Business term referring to the “type” of insurance policy/plan. Usethe family’s Subscriber ID# to help the Insurance Agent identify the “Product”or type of insurance plan.o Insurance Companies- Act as “Administrators” of many “Products” (akainsurance plans) for many companies. Some companies may offer severalinsurance plans. These insurance plans may or may not be New York StateRegulated.o NOTE: A Health Insurance Policy can be written so they are covered in morethan one state. Regulation depends upon which state wrote or issued thepolicy. That state that wrote or issued the policy is the state that regulates thatpolicy. How to get to the right person when calling an insurance companyo Select “Non-Member” option if there is one. If not, proceed as “Member” andenter “Policy Number”. This will send you to the Department who managesthis type of policy. Make your way through the prompts to speak to arepresentative.o Tell them who you are, where you are calling from and why you are calling.Reassure the representative you are looking to find out what type of “Product”it is. Reassure the representative you are asking for general information aboutthe policy, not specific information about the child/family. List of things to ask when you connect to the person who can help you with productinformationo Ask “Are (the child’s name) benefits covered under an Administrative ServicesOnly (ASO) plan?” If yes, ask whether the plan is a Municipal CooperativeHealth Benefit Plan, e.g., such as a local school district, issued in NYS. If yes,the plan is NYS Regulated. If no, the plan is not regulated by NY State (see ivbelow).o Ask what type of product it is, e.g., is it a fully insured plan, self-funded plan,Health Spending Account, etc.o If it is a fully insured plan, ask where it was issued or written. If the plan wasissued or written in New York State, it is Regulated/Insured by New York StateInsurance Law. If the Representative states it’s a privately-owned policy or iswritten/issued from another state, it is not regulated by New York StateInsurance Law.o Ask the Representative for the address or fax number for where to send the“Request for Coverage Information” form and to whose attention.Page 3 of 5Revised October 2019

oAsk the Representative for the ‘Claims Address’ and the ‘CorrespondenceAddress’ (these addresses may be different and may affect providers' noticeof subrogation). Document the correspondence address in the commentssection of the insurance page in NYEIS.ii. This determination must be made at the plan level (e.g., a single insurance company mayhave both regulated and non-regulated plans)iii. The Child Health Plus program is administered by a number of health plans throughoutthe state. In all cases, the Child Health Plus program’s administrator is subject to NewYork State Insurance Law with regard to the Early Intervention Program.iv. Self-insured/self-funded plans are typically not regulated (under a self-funded healthbenefit plan, the employer pays for its employees’ health care costs out of its generalassets or a fund that the employer has established for health benefits). Please Note:Some self-insured/self-funded plans to Municipal Corporation Health Benefit Plans, e.g.Counties, School Districts, may be self-funded but are still subject to NYS Insurance Lawand therefore regulated by NYS.v. Plans that are issued/written outside of New York State are not regulated (e.g., BlueCross/Blue Shield plans that are issued in another state are not regulated)vi. Health Spending Accounts/Health Savings Accounts (HSAs) are medical savingsaccounts and are not considered insurance; information regarding these accounts shouldnot be collected or entered into NYEISIt is very important for service coordinators to obtain the most recent and accurate insuranceinformation. Service coordinators should speak with parents about the type of insurance plan theyhave in case the parent can identify if it is self-funded, issued or written outside of New York State,or if it is, or is not linked to, a Health Spending/Savings Account. Parents can obtain informationabout their insurer’s payment of EIP services from the Explanations of Benefits (EOBs) they receivefrom their insurer. Service Coordinators should call the insurance company to verify the planinformation and mail Form D, Request for Coverage Information (Tool Kit Item 6) and Form CAuthorization to Release Health Insurance Information (Tool Kit Item 5) to ensure that they haveaccurate information on whether the child’s insurance plan is regulated or not regulated.b. If the child’s insurance is regulated by New York State Insurance Law:i. Review with the parent the Insurance Policies Regulated by New York State section ofthe Parent Notice Regarding Insurance (Tool Kit Item 9)ii. Ensure that the parent fully understands the information in this notice.c. If the parent’s insurance is NOT regulated by New York State Insurance Law:i. Review with the parent the Insurance Policies Not Regulated by New York State sectionof the Parent Notice Regarding Insurance (Tool Kit Item 9)ii. Ensure that the parent fully understands the information in this notice.4) Initiate the process of obtaining information from the insurer on the extent of benefits available to thechild under the child’s insurance policy (because EIP services are carved out of Medicaid ManagedCare and paid directly by Medicaid, this section does not apply to Medicaid Managed Care plans)Page 4 of 5Revised October 2019

a. Complete Form D (Tool Kit Item 6), Request for Coverage Information (the service coordinatorshould fill out the information in the box at the top of the page)b. Send Form C and Form D together to the insureri. The insurer is required to return information on the extent of benefits available to the childto the service coordinator and the municipality (section 3235-a of New York StateInsurance law) within fifteen days of the insurer’s receipt of the written request forcoverage information and the notice authorizing the release of this informationc. Enter the information returned from the insurance company into NYEISd. The completed and signed forms (Authorization to Release Health Insurance Information andRequest for Coverage Information) should be uploaded to the child’s integrated case home pagein NYEIS and sent to the child’s EIP providers upon provider request5) Document in service coordination notes all efforts (whether billable or not) to obtain accurate insuranceinformation. All information obtained must be maintained by the service coordinator as follows:a. Fill in the Child’s NYEIS reference number on the top left of every completed formb. Complete Form A, Collection of Insurance Information. Upload Form A into NYEIS.c. Enter the child’s insurance information, including Medicaid, Medicaid Managed Care, and ChildHealth Plus policy information, directly into NYEIS after verifying whether the insurance isregulated or non-regulated. Complete the required fields in NYEIS, including:i. The ‘Commercial Insurance’ pages (use the link for ‘Insurance Coverage’ on the leftnavigation bar of the child’s home page)ii. The Medicaid pages (use the link for ‘Insurance Coverage’ on the left navigation bar ofthe child’s home page)iii. For instructions on entering insurance information into NYEIS, please reference thefollowing resources: NYEIS User Manual Unit 4: Case ManagementNYEIS User Manual Unit 10: Municipal AdministrationItems 12 and 13 in this tool kitd. Upload a copy of each completed form to the child’s integrated case home page in NYEIS afterthe insurance information has been entered into the child’s insurance page in NYEIS.e. Notify all billing providers and the Municipality that these completed forms are accessible onNYEIS and will be mailed to them upon request, within 14 days of receipt of that request.f.Maintain a copy of all completed forms in the child recordPage 5 of 5Revised October 2019

InsuranceTool Kit Item 2NEW YORK STATE DEPARTMENT OF HEALTHBUREAU OF EARLY INTERVENTIONOngoing Service Coordinator Insurance Responsibilities1) Service coordinators must provide parent(s) with a copy of the Parent Notice Regarding Insurance (ToolKit Item 9) annually and review at least quarterly and at any time a child’s insurance changes, with thefamily the requirements in New York State Public Health and Insurance Law:a. Under New York State Public Health Law (PHL), Early Intervention Program (EIP) services mustbe provided at no cost to parents [Section 2557 of PHL, 10 NYCRR Section 69-4.1(m)(1)(iv)(d)]b. Commercial Insurance and Medicaid are part of New York State’s system of payments for earlyintervention services. These third-party payors are important resources for the EIP (Section 2559of PHL)c. Insurance will only be accessed for reimbursement of early intervention services if the child’spolicy is subject to New York State Insurance Law (regulated).i. EIP providers are required to first bill third-party insurance, including commercialinsurance and Medicaid, and are responsible for providing the subrogation notice (seeTool Kit Item 11)ii. Service coordinators are responsible for informing EI service providers that they canaccess information about the child’s insurance coverage in NYEIS and a copy of thecompleted Collection of Insurance Information and the Child Insurance Information formswill be mailed to them if requested within 14 days of receipt of the requestiii. Providers will receive payment from municipal funds (escrow account) for services thatare partially reimbursed or denied by the insurer, if the provider claim has met all otherapplicable early intervention billing and claiming rulesiv. The Medicaid Program covers all EIP services at the EIP payment rates established bythe Statev. Providers are prohibited from seeking payment for early intervention services from theparentd. All EIP services in an eligible child’s IFSP, and service coordination and evaluations, must beprovided if the child is uninsuredi. If a child is uninsured, the service coordinator is responsible for assisting the parent inidentifying and applying for benefit programs for which the family may be eligibleincluding Medicaid, Child Health Plus, and Social Security Disability Income, however,the parent is not required to enroll in order for EIP services to be providedii. Form B, Child Insurance Information, includes a Parent Attestation of No Insurancesection. Parents must sign this attestation if their child does not have health insurancecoverage. A new attestation must be signed by the parent at each IFSP meeting/review(unless the child has obtained insurance coverage)iii. Service Coordinators must obtain written parental consent on Form C (Authorization toRelease Health Insurance Information)Page 1 of 6Revised October 2019

iv. Upload Form B to the child’s integrated case in NYEIS. Notify all billing providers and theMunicipality that these completed forms are accessible on NYEIS and will be mailed tothem upon request within fourteen days of receipt of the requeste. Protections for use of regulated insurance:i. Parents do not pay any out-of-pocket costs, such as deductibles or co-payments for EIPservicesii. Insurers are prohibited from charging any benefits paid for EIP services against anymaximum annual or lifetime policy limits ("caps")iii. Early Intervention visits reimbursed by the insurer cannot reduce the number of visitsotherwise available to the child and family for health careiv. Insurers cannot discontinue or fail to renew a child’s insurance coverage solely becausea child is receiving EIP servicesv. Insurers cannot increase health insurance premiums solely because a child is receivingEIP servicesvi. If a child’s insurance plan is not regulated by New York State Insurance Law, the plan willnot be billed for EI services. However, the non-regulated insurance plan information mustbe recorded in NYEIS. See Tool Kit Item 13 for detailed information.f.Non-regulated insurance: If a child’s insurance is not regulated by New York State InsuranceLaw, their insurance benefits may not be protected as above in (e) if billed for EIP services.Therefore, non-regulated insurance is not billed for EIP services.2) Review insurance information quarterly with parents and update Form A and Form B as necessary (10NYCRR 69-4.6(d))a. Ask the family if there are any changes in their insurance status or coverage quarterlyb. If insurance has not changed, Form B (Child Insurance Information) should be reviewed andsigned by parent at each in person quarterly review. The service coordinator must document thediscussion about insurance in their service coordinator notes, noting that there have been nochanges in the child’s insurance information.c. If insurance has changed:i. Service Coordinator should give the family Form B (Child Insurance Information) and the forminstructions.ii. Service Coordinators should review the instructions with parents and assist parents withcompleting Form B (Child Insurance Information).iii. Obtain written parental consent on Form C (Authorization to Release Health InsuranceInformation).3) Determination of Insurance Plan Informationa. Determine if the child’s insurance plan is regulated by New York State Insurance Lawi. Contact the insurer directly to identify if the child’s plan is regulatedPage 2 of 6Revised October 2019

List of things to know before callingo Product- Business term referring to the “type” of insurance policy/plan. Weuse the family’s Subscriber ID# to help the Insurance Agent identify the“Product” or type of insurance plan.o Insurance Companies- Act as “Administrators” of many “Products” (akainsurance plans) for many companies. Some companies may offer severalinsurance plans. These insurance plans may or may not be New York StateRegulated.o NOTE: A Health Insurance Policy can be written so they are covered in morethan one state. Regulation depends upon which state wrote or issued thepolicy. The state that wrote or issued the policy is the state that regulates thepolicy. How to get to the right person when calling an insurance companyo Select “Non- Member” option if there is one. If not, proceed as “Member” andenter “Policy Number”. This will send you to the Department who managesthis type of policy. Make your way through the prompts to speak to aRepresentative.o Tell them who you are, where you are calling from and why you are calling.Reassure the Representative you are looking to find out what type of“Product” it is. Reassure the representative you are asking for generalinformation about the policy, not specific information about the child/family. List of things to ask when you connect to the person who can help you with productinformationo Ask “Are (the child’s name) benefits covered under an Administrative ServicesOnly (ASO) plan?” If yes, ask whether the plan is a Municipal CooperativeHealth Benefit Plan, e.g., such as a local school district, issued in NYS. If yes,the plan is NYS Regulated. If no, the plan is not regulated by NY State (see iv.below).o Ask what type of product it is, i.e., is it a fully insured plan, self-funded plan,Health Spending Account, etc.o If it is a fully insured plan, ask where it was issued or written. If the plan wasissued or written in New York State, it is Regulated/Insured by New York StateInsurance Law. If the Representative states it’s a privately-owned policy or iswritten/issued from another state, it is not regulated by New York StateInsurance Law.o Ask the Representative for the Address or Fax number for where to send the“Request for Coverage Information” form and to whose attention.o Ask the Representative for the ‘Claims Address’ and the ‘CorrespondenceAddress’ (these addresses may be different and may affect providers' noticeof subrogation). Document the correspondence address in the commentssection of the insurance page in NYEIS.ii. This determination must be made at the plan level (e.g., a single insurance company mayhave both regulated and non-regulated plans)Page 3 of 6Revised October 2019

iii. The Child Health Plus program is administered by a number of health plans throughoutthe state. In all cases, the Child Health Plus program’s administrator is subject to NewYork State Insurance Law with regard to the Early Intervention Program.iv. Self-insured/self-funded plans are typically not regulated (under a self-funded healthbenefit plan, the employer pays for its employees’ health care costs out of its generalassets or a fund that the employer has established for health benefits). Please Note:Some self-insured/self-funded plans to Municipal Corporation Health Benefit Plans, e.g.Counties, School Districts, may be self-funded but are also subject to NYS InsuranceLaw and therefore regulated by NYS.v. Plans that are issued/written outside of New York State are not regulated (e.g., BlueCross/Blue Shield plans that are issued in another state are not regulated)vi. Health Spending Accounts/Health Savings Accounts (HSAs) are medical savingsaccounts and are not considered insurance; information regarding these accounts shouldnot be collected or entered into NYEISIt is very important for service coordinators to obtain the most recent and accurate insuranceinformation. Service coordinators should speak with parents about the type of insurance plan theyhave in case the parent can identify if it is self-funded, issued or written outside of New York State,or if it is, or is not linked to, a Health Spending/Savings Account. Parents can obtain informationabout their insurer’s payment of EIP services from the Explanations of Benefits (EOBs) they receivefrom their insurer. Service Coordinators should call the insurance company to verify the planinformation and mail Form D, Request for Coverage Information (Tool Kit Item 6) and Form CAuthorization to Release Health Insurance Information (Tool Kit Item 5) to ensure that they haveaccurate information on whether the child’s insurance plan is regulated or not regulated.b. If the child’s insurance is regulated by New York State Insurance Law:i. Give parent the Parent Notice Regarding Insurance (Tool Kit Item 9)ii. Ensure that the parent fully understands the information in this notice.c. If the child’s insurance is NOT regulated by New York State Insurance Law,i. Give the Parent Notice Regarding Insurance (Tool Kit Item 9)ii. Ensure that the parent fully understands the information in this notice.4) If a family changes insurance plans or has new coverage, initiate the process of obtaining informationfrom the insurer on the extent of benefits available to the child under the child’s insurance policy(because EIP services are carved out of Medicaid Managed Care and paid directly by Medicaid, thissection does not apply to Medicaid Managed Care plans)a. Obtain parental consent on Form C, Authorization to Release Health Insurance Informationb. Complete Form D, Request for Coverage Information (the service coordinator should fill out theinformation in the box at the top of the page)c. Send Form C and Form D together to the insureri. The insurer is required to return information on the extent of benefits available to the childwithin fifteen days of the insurer’s receipt of the written request for coverage informationPage 4 of 6Revised October 2019

and the notice authorizing the release of this information to the service coordinator andthe municipality (section 3235-a of Insurance law)d. Enter the information returned from the insurance company into NYEIS.e. The completed and signed forms should be uploaded to the child’s integrated case home page inNYEIS, and sent to the child’s EIP providers upon provider request5) Obtain from the parent a written referral from the child’s primary health care provider as documentationof the medical necessity of EIP servicesa. Refer to the guidance regarding written referrals provided in the Instructions for Ongoing ServiceCoordinators, Collecting the Written Referral from Parents or Primary Care Providers (Tool KitItem 7)b. Use Form E, Written Referral from Primary Care Practitioner as needed for this purposec. Inform the child’s EIP providers that a written referral has been obtained from a child’s primaryhealth care practitioner to document medical necessity for the purpose of third-party claimingand the referral has been uploaded to NYEIS. This information should be sent to providers uponrequest. Providers can use this completed form to document medical necessity and to request aprior authorization from the insurer (the form contains a column for insurer to write in a priorauthorization number).*It is important for service coordinators to be aware that services in a child’s IFSP must begin timely;services should never be delayed due to commercial insurance requirements for a written referral orprior authorization.6) Document all efforts to obtain accurate insurance information and all information obtained must bemaintained by the service coordinator as follows:a. Fill in the NYEIS reference number on the top left of every completed formb. Review and initial Form A, Collection of Insurance Information if insurance has not changed. Ifinsurance has changed update Form A and upload into NYEIS.c. Document all efforts (whether billable or not) to obtain accurate insurance information in servicecoordination notesd. Enter the child’s and family’s insurance information, including Medicaid, Medicaid ManagedCare, and Child Health Plus policy information, directly into NYEIS. Form C- Authorization toRelease Health Insurance Information must be signed by the parent prior to any exchange ofinformation with an insurance company. After verifying with the insurance company whether theinsurance is regulated or non-regulated, complete the required fields in NYEIS, including:i. The ‘Commercial Insurance’ pages (use the link for ‘Insurance’ on the left navigation barof the child’s home page)ii. The Medicaid pages (use the link for ‘Insurance’ on the left navigation bar of the child’shome page)iii. For instruction on entering insurance information into NYEIS, reference the followingresources NYEIS User Manual Unit 4: Case ManagementPage 5 of 6Revised October 2019

NYEIS User Manual Unit 10: Municipal AdministrationItems 12 and 13 in this tool kite. Upload a copy of each completed form to the child’s integrated case home page in NYEIS afterthe insurance information has been entered into the child’s insurance page in NYEISf.Notify all EIP providers and the Municipality that new third-party insurance information has beenobtained and updated in NYEIS. Upon provider request, service coordinators will send providersa copy of the completed Collection of Insurance Information form, within 14 days of receipt of therequest.g. Maintain a copy of all completed forms in the child’s recordPage 6 of 6Revised October 2019

InsuranceTool Kit Item 3NEW YORK STATE DEPARTMENT OF HEALTHBUREAU OF EARLY INTERVENTIONNYEIS ChildReference #:Form ACOLLECTION OF INSURANCE INFORMATIONDATE INSURANCE INFORMATIONCOLLECTED/UPDATED:*Is the Insurance Plan Regulated byNew York State?YesNoIs the Insurance Plan:Primaryor SecondaryChild’s Name:Child’s Date of Birth:Child’s Gender:Parent/Guardian Name:Parent/Guardian Date of B

INSURANCE . Tool Kit for Service Coordinators . Tool Kit Items: 1. Initial Service Coordinator Insurance Responsibilities 2. Ongoing Service Coordinator Insurance Responsibilities 3. Collection of Insurance Information – Form A 4. Child Insurance Information – Form B 5. Authorization to Release Health Insurance Information – Form C 6.