Medicaid Parent Consent Form - New Hanover County Schools printable pdf download

One-time Consent to Access Public Benefits and Release Personally Identifiable Information

to the North Carolina Medicaid Program

New Hanover County Schools

6410 Carolina Beach Rd Wilmington, NC 28412

The federal special education law, the Individuals with Disabilities Education Improvement Act 2004 (IDEA), permits

school districts to seek payment from public insurance programs for some services provided at school. Under the Family

Education Rights and Privacy Act (FERPA), your consent is required for the school system to release information about

your child to the North Carolina Division of Medical Assistance Medicaid program in order to access your or your child’s

public benefits. You are entitled to a copy of any information the school system releases to the state Medicaid program.

You may inquire about this program or revoke your consent at any time by contacting Cindy Booth at

cindy.booth@nhcs.net. Your decision to allow the school district to release this information and access your or your

child’s public benefits will not affect your child’s special education program. This consent form is completed for each

child receiving special education evaluations and/or services.

The funds collected from Medicaid in this school system will be used to support and provide related services for

New Hanover County students.

Please mark appropriate statement(s) in one of the boxes below, sign and date at the bottom:

___ I give my consent for New Hanover County Schools to access my or my child’s North Carolina Medicaid

benefits for services provided through my child’s individualized education program (IEP). My signature does not

give consent to bill my private insurance company. The school system may release the following information to

access these public benefits:

• My child’s name and Social Security Number;

• My child’s date of birth;

• My child’s IEP documentation including evaluations;

• The dates and times services are provided to my child at school;

• Reports of my child’s progress, including therapist notes, progress notes and report cards.

___ And, I understand:

• My child will continue to receive IEP services at no cost to me.

• I can revoke my consent at any time and withdrawing my consent does not relieve the school district of its

responsibility to ensure that all required services are provided at no cost to me.

___ I do not give my consent for this information to be released. I understand refusing to consent or revoking consent

does not change the school district’s responsibility to provide IEP services at no cost to me.

Child’s full name:___________________________________________

Parent’s or guardian’s name (printed):____________________________

Parent or guardian’s signature:__________________________________

Date signed:____/____/________

February 2014

Medicaid Parent Consent Form - New Hanover County Schools