Consent To Access Medicaid And Release And Exchange Confidential Information printable pdf download

Date:

Region IX Education Cooperative

237 Service Road, Ruidoso, NM 88345

575-257-2368

CONSENT TO ACCESS MEDICAID AND RELEASE AND EXCHANGE CONFIDENTIAL

INFORMATION

School District (Distrito Escola)_______________________________________________________

Student Name(Nombre del Estudiante)_________________________________________________

Date of Birth (Fecha de Nacimiento)__________________ SS# (De Seguro)___________________

Address (Domicillio)_________________________________Phone(Telefono)__________________

TO THE PARENT: Enclosed with this CONSENT is a WRITTEN NOTIFICATION.

The school district must obtain your informed consent before it may access for the first time your child’s Medicaid benefits to

pay for Medicaid-Eligible IEP services and discloses necessary information from your child’s school records to complete the

billing process. If you indicate YES in response to all of the statements below and sign at the bottom, you will be giving your

consent for the school district, now and in the future, to access your child’s Medicaid benefits to pay for Medicaid-Eligible IEP

services and to disclose confidential information from your child’s education records to obtain prior authorization from your

child’s Primary Care Provider (PCP) to complete the billing process.

Once the school district obtains your one-time consent, unless you subsequently revoke your consent, the school district will

not be required to obtain any further parental consent to release and exchange confidential information with your child’s PCP

and Medicaid for purposes of billing Medicaid, and to bill Medicaid even when there is a change in the type, amount, or cost of

services to be billed to Medicaid.

However, the school district must annually provide you with written notification to ensure

that you understand your rights.

This consent for disclosure (release and exchange of confidential information) is for the release and exchange of your child’s

record(s)/confidential information between the school district, your child’s Primary Care Provider (PCP) and the Medicaid

agency.

Confidential Education Record Information to be Released to your Child’s Primary Care Provider (PCP) and Medicaid:



Billing information such as your child’s name, date of birth, Medicaid number.



A current copy of your child’s Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP) reflecting

the Medicaid services to be billed.



Any evaluations conducted or maintained by the School District as part of your child’s education records that demonstrate

the medical necessisity of the services specified in the IEP or IFSP.



Other information from your child’s education records as may be necessary to clarify the nature and need for the services

specified in the IEP or IFSP.



The dates and frequency of the billed services provided.

Confidential Medical Information to be Released by your Child’s Primary Care Provider (PCP):



The Primary Care Provider (PCP) shall be asked to sign and return the individualized treatment plan (ITP) portion of the

IEP or IFSP.



Other information from your child’s medical records as may be necessary to clarify the nature and need for the services

specified in the IEP or IFSP so that the PCP may order or authorize such services.

State the purpose of the disclosure (if any) by the school district:



In order to bill Medicaid for those services under the IDEA specified in your child’s IEP that may be paid for by Medicaid

(Medicaid-Eligible IEP services). To bill Medicaid:

Services must be medically necessary, must be ordered or authorized by the child’s Primary Care Provider

(PCP), and must meet the needs specified in the IEP or the IFSPl

Services require prior authorization by the Primary Care Provider (PCP). The requirement for prior authorization

is met when the PCP signs the ITP portion of the IEP or IFSP.

Complete copies of the IEPs or IFSPs, with the ITP portions of the IEPs or IFSPs signed by the primary care

provider (PCP), must be maintained as part of the required records.

If consent is granted, the Primary Care Provider to whom the School District discloses information may not disclose the

information to any other party without the prior consent of the parent or eligible student.

Please respond to each statement with a YES or NO and sign at the bottom.

I understand and give my consent for the school district to access my child’s Medicaid benefits to pay for

Medicaid-Eligible IEP services and to disclose confidential student information to the Medicaid agency as necessary

Yes

to complete the billing process.

Consent To Access Medicaid And Release And Exchange Confidential Information

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