Form 124 - Sharing Information With Medicaid Or Nj Familycare
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1
2SHARING INFORMATION WITH MEDICAID or
NJ FAMILYCARE
Dear Parent/Guardian:
If your children get free or reduced price school meals, they may also be
able to get free or low-cost health insurance through Medicaid or NJ
FamilyCare.
Children with health insurance are more likely to get
regular health care and are less likely to miss school because of
sickness.
Because health insurance is so important to children’s well-being, the
law allows us to tell Medicaid and NJ FamilyCare that your children
are eligible for free or reduced price meals, unless you tell us not to.
Medicaid and NJ FamilyCare only use the information to identify children
who may be eligible for their programs. Program officials may contact
you to offer to enroll your children. Filling out the Free and Reduced
Price School Meals Application does not automatically enroll your
children in health insurance.
If you do not want us to share your information with Medicaid or NJ
FamilyCare, fill out the form below and send in (Sending in this form will
not change whether your children get free or reduced price meals).
No! I DO NOT want information from my Free and Reduced Price
School Meals Application shared with Medicaid or the State
Children's Health Insurance Program (NJ FamilyCare)
If you checked no, fill out the form below to ensure that your
information is NOT shared for the child(ren) listed below:
Child's Name: _______________________School:________________________
Child's Name: _______________________School:________________________
Child's Name: _______________________School:________________________
Child's Name: _______________________School:________________________
Signature of Parent/Guardian: ____________________________Date: _______
Printed Name:____________________ Address:_________________________
Return this form to your child’s school, ONLY if you do NOT wish your
information to be shared with Medicaid or NJ FamilyCare.
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Parent category: Medical