Parental Consent Medi-Cal Eligibility Verification



Parental Consent Form

Federal law encourages school districts to submit claims for health-related services provided to special education students or students referred for special education. These include physical therapy, occupational therapy, speech therapy, audiology, nursing, psychology, counseling, and Targeted Case Management (TCM) services.

With your permission, we will submit your student’s name, birth date, and gender to the Department of Health Services to verify eligibility. Such a request will in no way negatively impact services included in your child’s Individualized Education Program (IEP) or your Individualized Family Services Plan (IFSP). If your child is currently Medi-Cal eligible, the school district will bill for health-related services that are listed in your child’s IEP/IFSP.

By giving consent, you are acknowledging that:

1. You have been fully informed of the district’s intent to determine Medi-Cal eligibility and bill for IEP/IFSP services.

2. You understand that the granting of consent is voluntary on your part and may be revoked at any time.

3. If you revoke consent, the revocation is not retroactive, which means that it does not negate any activity that has already taken place.

| |I do give consent to verify eligibility and submit claims to Medi-Cal. |

| |

| |I do not give consent to verify eligibility and submit claims to Medi-Cal. |

| | | |

|Parent/guardian signature | |Date |

| | |

| | | |

|Student name (print) | |Date of birth |

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