The Early Intervention Service Broker shall complete the "Insurance Declination Form," if public or private health insurance is not accessed for any of the family related circumstances:

1. The family declines to provide health insurance information to the Early Intervention Colorado Program;

2. The family was asked and could not or did not provide documentation from the health insurance carrier; or

3. The family declines to give consent to access insurance benefits for the child because the use of the public or private health insurance would result in one of the system exceptions to the use of private or public health insurance plans.

The completed form shall be filed in the child's Early Intervention Colorado Program record and a copy submitted to the Early Intervention Colorado Program staff at the CDHS.