Medicaid Consent Form Suwannee County Schools

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Parental Consent to Release Personally Identifiable Information for Medicaid Reimbursement
Suwannee County School District
The Individuals with Disabilities Education Act 2004 (IDEA) permits school districts to seek
reimbursement from Medicaid for services provided at school. Our district wishes to seek reimbursement
for certain services provided to your child by accessing Medicaid. IDEA requires that we obtain your
written informed consent for the purpose of releasing certain information related to seeking Medicaid
reimbursement. Medicaid reimbursement helps the school district fund costs of providing special
education and related services.
Consent given or denied: (please read, initial, sign and date at the bottom)
____ I understand and give my consent to the district to share information about my child with the state
Medicaid Agency (State of Florida Agency for Health Care Administration), its fiscal agent and the
district’s Medicaid billing agent or billing facilitator for the district to verify Medicaid eligibility, seek
Medicaid reimbursement and satisfy audit review requests related to services provided to my child. I
understand that if I refuse to give consent, my refusal does not relieve the school district of its
responsibility to provide required IEP and other services at no cost to me. I understand that I may revoke
this consent to release information for Medicaid billing at any time; if I revoke this consent, it will apply
to billing services from that date forward.
The information shared may include my child’s name, date of birth, address, primary special education
disability, Social Security number, Florida Medicaid identification number, and the type and amount of
health services provided, including the times and dates the services were provided. Services may include
assistive communication services, physical therapy services, speech therapy services, hearing and
language therapy services, occupational therapy services, behavioral services, transportation services,
nursing services.
The records to be released/exchanged may include individual education plans (IEPs), assessment and
eligibility records, related service therapy records and logs, transportation logs, progress notes and
nursing reports/records.
____ I do not give my consent to the district to share information about my child in order for the district
to verify Medicaid eligibility, seek Medicaid reimbursement, and satisfy audit and review requests related
to services provided to my child.
Parent/Guardian Signature: _________________________________ Date signed: ___/___/___
Parent/Guardian’s Name (printed): __________________________________________________
Student/Child’s Full Name (printed): ________________________________________________
Student/Child’s Date of Birth: ___/___/___

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