Sample Consent Form to Bill Medicaid
English - Sample Consent Form to Bill Medicaid -Word(27KB)
Spanish - Sample Consent Form to Bill Medicaid -Word(27KB)
Russian - Sample Consent Form to Bill Medicaid -Word(30KB)
Haitian Creole - Sample Consent Form to Bill Medicaid -Word(27KB)
Chinese - Sample Consent Form to Bill Medicaid - Word (26 KB)
Korean - Sample Consent Form to Bill Medicaid - Word (32 KB)
Dear Parent/ Guardian of _______________________:
This is to ask your permission (consent) to bill Medicaid for Medicaid reimbursable services that are on your child's individualized education program (IEP). Schools in New York State routinely access Medicaid funding to help meet costs of providing special education services. Please read and confirm the following information:
I, _______________________________________________ as the parent/guardian of ____________________________________________,
(Print child’s name)
give permission for the school district / municipality to use Medicaid to pay for special education services rendered on behalf of my child for all Medicaid eligible services listed on my child’s IEP dated: ___________________________________.
I understand that the use of Medicaid insurance for special education services will not decrease the available lifetime coverage, increase premiums or lead to the discontinuation of benefits, result in my family paying for other services required for my child outside of school that would otherwise be covered by the Medicaid program or otherwise diminish my family’s insured benefits under the Medicaid program and that I will not incur an out-of-pocket expense such as payment of a deductible or co-pay amount.
I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s entitlement to a free appropriate public education (FAPE) is in no way dependent on my granting consent and that, regardless of my decision to provide this consent, all the required services on my child’s IEP will be provided to my child at no cost to me.
Parent/Guardian Signature: _______________________ Date: ______________