Rogers Public Schools

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Parental Consent to Release Personally Identifiable Information

Email *

In compliance with the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. 1232g; 34 CFR Part 99)

Parent/Guardian Name *

Parent/Guardian - City *

Parent/Guardian Address - Number, Street, Unit number *

Parent/Guardian State *

Parent/Guardian Zip Code *

With parental consent, the school district can seek Federal Medicaid reimbursement for the cost of health services the school district provides to children who are eligible for Medicaid. In order to seek the Federal Medicaid funds for reimbursement, permission is needed to release personally identifiable information/student education records (Hearing and Vision Screenings, Evaluations/Therapy) to Medicaid Billing Agent for the purpose of billing Medicaid. PLEASE ACKNOWLEDGE YOUR CONSENT: *

Yes

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