<p>INITIAL NOTICE REGARDING USE OF PUBLIC BENEFITS OR INSURANCE AND CONSENT TO RELEASE STUDENT INFORMATION</p><p>You are receiving this notification to give you information about your rights and protections under Part B of the Individuals with Disabilities Education Act (IDEA) so that you can make an informed decision on whether you should give written consent to allow your school district (LEA) to use your child’s public benefits or insurance for the first time, to pay for special education and related services that your school district provides.</p><p>By signing below you acknowledge that: . Granting this consent is voluntary, and the consent may be revoked at any time. . If either parent revokes consent, that revocation is not retroactive and does not negate an action that has occurred after the initial consent was given and before the consent was revoked. . If you choose not to consent or later revoke your consent, your school district still has the responsibility of ensuring your child is provided all required special education and related services at no cost to you. . You have the right to request that this consent be provided in your native language, or through another mode of communication, if feasible. . Your rights are preserved under Title 34 Code of Federal Regulations 300.154 and 300.622; Family Education Rights Privacy Act of 1974, Title 20 of the United States Code, Section 1232 (g), Title 34 Code of Federal Regulations, Section 99.</p><p>Furthermore, by signing below you acknowledge that the Local Education Agency (LEA):  May not require you to sign up for or enroll in public benefits or insurance programs (Medi-Cal) in order for your child to receive FAPE under Part B of the IDEA (34 CFR 300.154[d][2]).  May not require that you incur out-of-pocket expenses such as a deductible or co-pay for filing a claim.  May not use a student’s benefits under Medi-Cal if that use would: a) Decrease available lifetime coverage for any other insured benefit, b) Result in your family paying for services that would otherwise be covered by the public benefits or insurance program (Medi-Cal) and are required for your child outside of the time the child is in school, c) Increase premiums or lead to discontinuation of public benefits or insurance (Medi-Cal), d) Risk loss of eligibility for home and community-based waivers, based on aggregate health related.</p><p>STUDENTS NAME: ______(printed)</p><p>I authorize the ______(LEA) to release my student’s information for the limited purposes of billing Medi-Cal/Medicaid including my child’s name, date of birth, SSN, as well as their IEP designated service(s), the type(s) and number of services provided, their service date(s) and name of provider(s). </p><p>______Parent/Guardian Date</p><p>______Parent/Guardian Date</p><p>Form 48 - Revised 9/2013</p>