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Health Insurance Authorization Forms July 2016

The Health Insurance Authorization for Early Intervention Services Form, is used to obtain the written authorization from a parent that his or her child's health insurance plan will be accessed in order to pay for the cost of Early Intervention Services. By signing this form, the parent:

1. Authorizes the personally identifiable information to be released by the Early Intervention Service Broker to the health insurance carrier to process claims; and

2. Requests payment of benefits to the Early Intervention Service Broker for Early Intervention Services provided and claimed.

The form is also used to request confirmation of eligibility under Section 10-16-104(1.3), C.R.S. for the listed health insurance carrier.

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