Consent for Release of Information to Access Medicaid Reimbursement for Health Related Support Services

Our school district continues to participate in a system whereby the Federal Government’s Medicaid program reimburses local school districts for a portion of the costs of health related  services provided to Medicaid eligible children. Your child continues to receive services at no cost to you under this system. This initiative simply helps us optimize federal funds in support of local education, as well as offset some of the costs of these services, including special education, paid for by the local taxes. The information you voluntarily allow to be released by completing this consent form will only be used for the purposes identified. Our district has contracted the services of New Hampshire Medicaid to Schools  to confidentially administrate our Medicaid Program. 

With your permission, the school district will be able to seek partial reimbursement for services, including, among others, a hearing test or eye exam; a school physical; occupational or speech or physical therapy; some school nurse visits; and counseling services with the school social worker or psychologist. 

Please fill in the information below, sign the form, and return it to your child’s school.
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Email *
Parent/Guardian *
E-mail *
Student's First Name *
Student's Last Name *
Student's Date of Birth *
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School District:
 *
Parent/Guardian Initials *

As parent/guardian of the child named above, I give permission to the school district to disclose personally identifiable information concerning health-related support services for my child to the school districts and designees in SAU21 along with State and Federal Medicaid administration representatives for the sole purpose of claiming MEDICAID reimbursement for health-related support services in my child’s IEP and/or for other health related needs. I understand and agree that the School District may access my or my child’s Medicaid benefits to reimburse health-related support services). 

This permission is for any time my child is Medicaid eligible and in the event that my child becomes Medicaid eligible in the future for the purpose of the release of information relative to medically necessary services such as related services included in an Individualized Education Program (IEP). . I also understand that if I refuse to consent to the release of this information, my refusal does not relieve the school district of its responsibility to provide medically necessary services at no cost to me (34 C.F.R. §300.154 (2013)). I also understand that this consent is voluntary and may be revoked at any time, but that such revocation is not retroactive (34 C.F.R. §300.9 (2006)).


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