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Special Education Medicaid Initiative SEMI Parental Consent form


School DistrictOur school district is participating in the Special Education Medicaid Initiative SEMI program that allows In accordance with the Family Educational Rights and Privacy Act 34 CFR 9930

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Document on Subject : "Special Education Medicaid Initiative SEMI Parental Consent form"— Transcript:

1 Special Education Medicaid Initiative (S
Special Education Medicaid Initiative (SEMI) Parental Consent form ______________________________________________________________ School District Our school district is participating in the Special Education Medicaid Initiative (SEMI) program that allows In accordance with the Family Educational Rights and Privacy Act, 34 CFR 99.30 and Section 617 of the IDEA Part B, consent requirements in 34 CFR 300.622 require a onetime consent before accessing public benefits. information about services provided to your child, including evaluations and services as specified in my child's Individualized Education Program (IEP) (occupational therapy, physical therapy, speech therapy, psychological counseling, audiology, nursing and specialized transportation,) may be disclosed to Medicaid district. As parent/guardian of the child named below, I give permission to disclose information as described above and I understand and agree that Medicaid may access my child's or my public benefits or public insurance to pay for special ed the school district is still required to provide services to my child pursuant to his or her IEP, regardless of my Medicaid eligibility status or willingness to consentfor SEMI billing I understand that billing for these services by the district does notimpact my ability to access these services for my child outside of the school setting, nor will any cost be incurred by my family including copays, deductibles, loss of eligibility or impact on lifetime benefits. Child's Name: __________________________________ Parent/Guardian: _____________________________________________________________Date: ________/______/_____ I give consent to bill for SEMI: Yes No