Sample Consent Form for Accessing a Parent's or Student's Medicaid Insurance to Pay for Certain Special Education Services in a Student's Individualized Education Program (IEP)
Sample Consent Form for Accessing a Parent's or Student's Medicaid Insurance to Pay for Certain Special Education Services in a Student's Individualized Education Program (IEP)
English - Word 
(23 KB)
Spanish - Word (35 KB)
Chinese (Simplified) - Word (35 KB)
Russian - Word (39 KB)
Korean - Word (44 KB)
Haitian-Creole - Word (39 KB)
Dear Parent/ Guardian of _______________________:
This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance Program for special education and related services that are on your child's individualized education program (IEP).
This consent allows the school district to bill for covered health-related services and to release information to the school district’s Medicaid Billing Agent for that purpose.
I, _______________________________________________ as the parent/guardian of ____________________________________________,
(Print child’s name)
have received a written notification from the school district that explains my federal rights regarding the use of public benefits or insurance to pay for certain special education and related services.
I understand and agree that the school district may access Medicaid to pay for special education and related services provided to my child.
I understand that:
- Providing consent will not impact my child’s/my Medicaid coverage;
- Upon request, I may review copies of records disclosed pursuant to this authorization;
- Services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid;
- I have the right to withdraw consent at any time; and
- The school district must give me annual written notification of my rights regarding this consent.
I also give my consent for the school district to release the following records/information about my child to the State’s Medicaid Agency for the purpose of billing for special education and related services that are in my child’s IEP. The following records will be shared.
Records to be shared (such as records or information about services your child receives)
____________________________________________________
____________________________________________________
____________________________________________________
I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to receive special education and related services is in no way dependent on my granting consent and that, regardless of my decision to provide this consent, all the required services in my child’s IEP will be provided to my child at no cost to me.
Parent/Guardian Name and Signature:
_______________________
Print Name
________________________
Date