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