File:† JLCG*-E

 

 

 

Consent to Release Information

(Sample Form)

 

Colorado school districts are entitled by law to seek Medicaid reimbursement when the districts provide services to Medicaid-eligible students.† The following consent form is to authorize the South Conejos School District to release to Colorado Health Care Policy and Financing information related to Medicaid services provided to the student identified below as necessary to apply for and recover Medicaid reimbursement.

 

NOTE:† Participation in the school Medicaid reimbursement program does NOT adversely affect the studentís eligibility for future Medicaid services in any way.

 

I give consent and authorize the South Conejos School District to release to Colorado Health Care Policy and Financing (HCPF) information related to health and other Medicaid eligible services the district provides to the student identified below during the ____________school year, as frequently and comprehensively as necessary to apply for and recover Medicaid Partial Reimbursement for such services.

 

 

Student Name

 

 

Studentís Date of Birth

 

Studentís School

 

 

Studentís Medicaid Number

 

Parent/Guardian Name (or Student Over 18)

 

 

Studentís Social Security Number

 

 

Parent/Guardian Signature (or Student Over 18)

 

 

 

Date

 

If at any time you wish to revoke this permission, please contact________________.

 

 

Adoption date: September 22, 2014