Consent to bill Medicaid



|AUTHORIZATION FOR DISCLOSURE OF IDENTIFYING EDUCATION RECORD INFORMATION FOR SCHOOL-BASED MEDICAID REIMBURSEMENT |

|Document date:       FOR HEALTH–RELATED SERVICES Page    of    |

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|Student’s Name:       |District ID:       |State ID:       |Grade:    |Sex:   |

|Native Lang:       |Ethnicity:       |Birth Date:       |Age:    |

|District:       |School:       |

|Parent/Guardian Name:       |Home Phone:       |

|Address:       |

|Native Language:       |Daytime Phone:       |

|Parent/Guardian Name:       |Home Phone:       |

|Address:       |

|Native Language:       |Daytime Phone:       |

Student’s Name as it appears on Medicaid card

Birth Date       Medicaid ID #      . 34 CFR. 300.154D (d) (2) (D) (iv) (A) requires the District to obtain parental consent, each time that access to public benefits or insurance is sought as such access requires the sharing of identifiable information from the student’s education record pursuant to the Family Educational Rights and Privacy Act (FERPA).

I authorize School District Name to share necessary identifying information from my child’s education record to access federal Medicaid reimbursement for the health-related services identified on Student's Name IEP dated      .

I understand that if any additional Medicaid reimbursable services are added to this IEP after this date, additional written consent will be required in order for the district to claim federal reimbursement for any new service(s).

I understand that this consent is not transferable to a different school district. (Check either box.)

I give my continuing permission for my child’s health related services to be submitted to Medicaid for federal reimbursement each time services are provided. I understand that to submit the billing to Medicaid to be reimbursed that identifying information from my child’s education record (IEP) detailing the related services must be disclosed to, and submitted to Medicaid.

I understand that this consent is good for 365 days, to align with the date of my child’s IEP. I understand that I can revoke this permission at any time.

I understand if there is a change in the related services required by the IEP or the frequency or duration of related services is changed in a subsequent IEP meeting within 365 days, a new consent will be required.

I do not give my permission for my child’s health related services to be submitted to Medicaid for federal reimbursement at this time.

I understand that my refusal to allow the district to submit the billing for related services to Medicaid precludes the School District from accessing my child’s Medicaid benefit and that my denial of permission for such disclosure of information from my child’s education record will not impact my child’s access to a Free and Appropriate Public Education and/or required health-related services.

|Parent/Personal Representative/Adult Student’s Name: |      |

|Address: |      |

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|Signature: | |

|Date: | |

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