Nyc Early Intervention Program Car Service Information - Queens
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1NYC EARLY INTERVENTION PROGRAM CAR SERVICE INFORMATION – QUEENS
New York City Department of Health and Mental Hygiene Early Intervention Queens Car Service Vendor:
AMN MANAGEMENT, INC. • Dispatch: 718-326-5115 • Contact: Kathy
Instructions: Within two (2) business days of receiving a service authorization for car service from the Ongoing Service Coordinator (OSC), the Early
Intervention service provider agency Transportation Coordinator (TC) completes the Car Service Information Form and faxes it to the NYEIS
Administration Transportation Liaison at 347-396-8983 . The NYEIS Administration Transportation Liaison returns the approved form to the OSC via
Fax. The OSC attaches the approved Car Service Information Form to the child’s integrated case in NYEIS and faxes a copy to the TC.
Section I: Child and Family Information – Completed by Provider Agency Transportation Coordinator
Child’s Name (Last, First):
EI ID:
DOB:
Parent Name (Last, First):
Phone:
Name of Caregiver Accompanying Child:
Name of Alternate Caregiver:
Pick-up Address:
Drop-off Address:
Section II: Early Intervention Provider Agency Information - Completed by Provider Agency Transportation Coordinator
Agency Name:
Address:
Phone:
Fax:
Transportation Coordinator Name:
Transportation Coordinator HIN ID:
Section III: Service Authorization Information - Completed by Provider Agency Transportation Coordinator
Transportation SA Number:
Schedule
Authorization Period
Day(s) that child will
Session Start Time
Session End Time (AM/PM)
From: Date:
attend group
(AM/PM)
To: Date:
Monday
Comments:
Tuesday
Wednesday
Thursday
Friday
Car Service Vendor: Notification to Proceed with Car Service (NYC Bureau of Early Intervention Use Only)
AMN MANAGEMENT, INC. that car service has been approved and can be initiated to the Early Intervention provider
This form serves to advise
identified in Section II of this document on date:______________
Above please find the Parental Contact and Child Scheduling information. Vendor may contact the family to schedule the pick-up.
Contact New York City Bureau of Early Intervention at
nycnyeis@health.nyc.gov
if you have any questions.
NYC Bureau of Early Intervention Approval Signature:
Date:
NYCEIP Car Service Information Form – Queens 5 2015
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