ASD Student Medicaid Information
This form is for the confidential submission of relevant Medicaid plan information for students with a signed Medicaid Consent form to the ASD School-Based Medicaid office. This information will be utilized only to verify Medicaid reimbursement eligibility for services provided to the named student by Anchorage School District. This information will not be shared our utilized beyond this stated purpose. Inclusion of parent/guardian contact information is optional and will only be utilized to contact the parent/guardian in the event that additional information is required to verify the student's identity or Medicaid reimbursement eligibility.
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Email *
Student's Legal Last Name *
Student's Legal First Name *
Student's Date of Birth *
MM
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DD
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Student Medicaid Identification Number *
Parent or Legal Guardian's Name (First and Last)
Parent or Legal Guardian's Phone Number
Parent or Legal Guardian Email Address
Preferred Contact
A copy of your responses will be emailed to the address you provided.
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