MEDICAID PARENTAL CONSENT FORM by YxpQ1J13

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									                                                                                                      NC-10


                         MEDICAID PARENTAL CONSENT FORM

Name of Child ____________________________ Date of Birth ___________________

Child’s Medicaid Number ______________________ School _____________________

1.       Parental Consent (Please check A, or B)

         A.         _____ I have private insurance and understand that Medicaid is the payor of
                  last resort and will not reimburse for special education services if reimbursement
                  is available through my private insurance.

                      The district will not bill private insurance, nor will we access Medicaid if
                       you have private insurance.

                      Please disregard Part B and 2 of this form if you have checked A.

         B.       _____ I give my consent to the ______________ School District to submit
                  claims to the South Dakota Department of Social Services for special educational
                  evaluations and other covered therapy services including speech,
                  physical/occupational and counseling services as indicated on my child’s
                  individual education plan.

                      If you check B the following information must be completed.

         Name of Primary Care Physician: ______________________________________

         Name of Clinic: ____________________________________________________

         Address: ______ ________________________ ____________ ____ ________
                   PO Box       Street Address          City   State Zip Code

2.       Authorization of Release of Information

         _____ I authorize the release for any medical information by the __________________
         School District to the South Dakota Department of Social Services as necessary to
         process Medicaid claims and share Medicaid reports.

THIS FORM WILL BECOME PART OF THE STUDENT’S EDUCATIONAL
RECORD AND SHALL BE VALID FOR ONE YEAR.

Consent:
ARSD 24:05:30:17. Consent. “Consent” means that the parents have been fully informed of all
information relevant to the activity for which consent is sought, in the native language, or other mode of
communication; the parents understand and agree in writing to the carrying out of the activity for which
consent is sought, and the consent describes that activity and lists any records which will be released and to
whom; and the granting of consent by the parent is voluntary and may be revoked in writing at any time.


Signature ________________________________ Date ________________________________


                                                                                                       02-07

								
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