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* 1. Indicate your present position in NYS Early Intervention. Check ALL boxes that apply.

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* 2. Indicate the municipalities that you presently provide Early Intervention Services in and/or reside in.

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* 3. In the space provided, indicate your gross dollar amount invoiced versus your gross dollar amount received from April 1st to date. Reflect the percent due.

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* 4. If you are a subcontractor, how has your reimbursement been impacted since April 1st?

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* 5. If you are a parent, describe how this early intervention transition has impacted you.

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* 6. Describe the role of Service Coordinators in the billing process in your county at present and add any relevant comments.

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* 7. Has your county consistently deposited money into the escrow and in a timely manner?

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* 8. Please rate the present status of Early Intervention invoicing. Consider EIBilling.com and Insurance Company compliance in your response. Add additional comments as needed.

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* 9. Have you applied for the Safety Net Payment?

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* 10. Is the projected Safety Net Payment amount accurate in the system through 7/31/13?

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* 11. If you have applied for the Safety Net Payment, have you received your lump sum reimbursement to date?

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* 12. Please list the name of ALL agencies that have closed in your county this year as a result of the current Early Intervention Crisis. Reflect whether the agencies that closed are large or small in size.

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* 13. At present, what is the status of waiting lists for Early Intervention services in your county. Provide details if they are available to you.

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* 14. What actions have you personally taken to effect change in your county?

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* 15. In your estimation what has been the most significant impediment to timely reimbursement? Please rank your choices 1 thru 14 with number 1 being the most significant impediment.

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