<p> Combined Consent to Share Data and Seek Reimbursement for Individualized Education Program (IEP) Health Related Services</p><p>Please print information below:</p><p>Child’s Legal Name: ______DOB: ______</p><p>Child’s Home Address: ______Street City/State/Zip</p><p>Parent(s) Name: ______</p><p>School District Name: ______District #:______</p><p>Authorization: (Currently receiving Medical Assistance or Medicaid)</p><p>If you have applied for and received benefits from Minnesota Health Care Programs (MHCP) you have given your child’s school district consent to bill MHCP for qualifying services provided by our qualified professionals within the application. The type, amount, and frequency of services are in your child’s Individualized Education Program (IEP).</p><p>In accordance to 34 CFR 300.154 (d)(2)(v) this consent verifies you understand and agree that your child’s school may access your child’s public benefits or insurance to pay for school-based health related services including Speech/Language Therapy, Occupational Therapy, Physical Therapy, Paraprofessional/PCA, Nursing, qualifying special transportation, Assistive Technology Devices, CTSS and evaluations by our school psychologists. </p><p>The data shared with the MN Dept of Human Services (DHS) to bill for services includes your child’s name, date of birth, member number, dates of services, and type of service codes. In audits by DHS, or the U.S. Department of Health and Human Services (DHHS), the data shared may also include your child’s IEP, evaluation reports, service and attendance records, and medical orders.</p><p>Authorization: (Not currently receiving Medical Assistance or Medicaid)</p><p>This consent verifies that you have been informed in writing that yearly the school district will verify if your child is covered under MA, and if so your child’s school district will seek reimbursement for qualified services as listed above.</p><p>------Important Information for Parents:</p><p>School-based services do not count against parental fees, you will not have to pay any co-payment for school-based services, and school-based services do not count against limits for CAC, CADI, DD or other waivers. The school district will not bill private insurance.</p><p>This consent starts on ______and is good as long as your child is eligible for special education. This consent verifies that you understand the reimbursement process for school-based services and that you have received a copy of the Notice of Procedural Safeguards. You have the right to receive a copy of all data shared with DHS or DHHS. You may withdraw your consent at any time in writing and your child’s IEP services will not change or stop.</p><p>------</p><p>Your signature allows your child’s school district to release information to DHS, DHHS, and to your child’s doctor/clinic for medical orders if your child receives nursing or personal care assistant services at school.</p><p>Parent/Legal Guardian Signature:______Date: ______</p><p>A copy is as valid as an original</p>