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PARENTAL CONSENT FOR RELEASE OF EDUCATIONAL INFORMATION FOR MEDICAID FUNDING

TERMS, RIGHTS AND RESPONSIBILITIES

By signing this application, I understand and confirm that:



I, _______________________________________________, as parent/guardian of
           (Print name of parent or person in parental relationship)                                               

_____________________________________________________________,
                                                            (Print child’s name)   

give permission to the public agency (school district, municipality or Medicaid provider) to use Medicaid to pay for IEP services and to such public agency and to each approved private special education school or provider who provides IEP services to my child to disclose information regarding diagnosis and procedure codes for billing Medicaid for services described in my child’s IEP and for evaluations in relation to the services; and in the event of an audit, documentation required to support services reimbursed by Medicaid from my child’s educational records to local, State and federal agency representatives for the sole purpose of claiming Medicaid reimbursement for covered health-related support services for each service and for each school year in which service is provided as recommended in my child’s IEP if my child is or becomes Medicaid-eligible. 

I give my consent voluntarily and understand that I may withdraw that consent at any time.  I also understand that my child’s entitlement to a free appropriate public education (FAPE) is in no way dependant on my granting consent.

 

Signature: _________________________________      Date: ______________