NYCEIP AT Medical Necessity Justification bFormb with bb - NYCgov 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the child's name, date of birth, and EI number at the top of the form. Ensure all information matches what is recorded in NYEIS.
  3. Fill in the service type and location, along with the child's diagnosed conditions and corresponding ICD-10 codes.
  4. Document your contact with the TRAID Center by noting the date and outcome of your inquiry regarding device availability.
  5. In section two, specify the requested ATD category and list any necessary accessories, providing justifications for each based on how they support the child’s functional skills.
  6. Complete sections detailing how the ATD will improve functional capabilities, address safety precautions, and integrate into daily routines.
  7. Finally, ensure both parent/caregiver and provider signatures are included before submitting to the appropriate coordinator.

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For children from birth to 3 years old - contact your states early intervention service for information on how to receive services. For children 3 years or older - contact your local elementary school or school district to request an evaluation. Your child can be evaluated even if they do not attend public school.
Applicants must have documentation of a minimum of 1,000 clock hours prior to the date of application to the Department for approval, delivering such service to children under 5 years of age in an early intervention, clinical pediatric, early childhood education program, which may include relevant experience obtained
A letter of medical necessity, whether being submitted to the Department of Human Services, a private insurance company or other funding source, should contain the information needed to convince the reader that the requested assistive technology is necessary to meet the medical needs of the person for whom the

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Early Intervention services are confidential, voluntary and free for families,* regardless of income, immigration or insurance status. *If you have health insurance, including Medicaid, it will be used to pay for Early Intervention services at no direct cost to you.
Families, doctors, and community members can make a referral by: Calling 311 and asking for Early Intervention. Completing the Early Intervention Program Referral Form (Fillable PDF) and faxing it to the Citywide Early Intervention Referral Unit.
If you think your child has a developmental delay and needs help, you can make a referral to EI by calling 311 and asking for Early Intervention, or completing the New York City Intervention Referral form and faxing it to (347) 396-8801.
To be eligible for services, children must be under 3 years of age and have a confirmed disability or established developmental delay, as defined by the State, in one or more of the following areas of development: physical, cognitive, communication, social-emotional, and/or adaptive.