Notice of Parent/Guardian Rights

Parental Consent to Access Public Benefits (Medicaid)

The Ohio Medicaid School Program

The Northridge School District has the opportunity to receive Federal Medicaid dollars through a program called the Ohio Medicaid School Program (MSP). Through this program, school districts can receive Medicaid dollars for services such as Speech, Audiology, Physical Therapy, Occupational Therapy, Nursing, Psychology, Counseling, and Social Work services. The district can receive funding when a student receives one or more of these services and the student has current Medicaid insurance coverage. In the process of billing Medicaid for these services, certain billing information must be shared with the Ohio Department of Medicaid. Before the district can submit claim data for Medicaid billing purposes, we must first obtain a signed PR-10 Parental Consent to Share Health Information for the Ohio Medicaid School Program form.

This annual notice is to inform you of all of your legal protections and rights under the individuals with Disabilities Education Act (IDEA) and the Family Educational Rights and Privacy Act (FERPA).

Your consent is voluntary. You have the right under 34 CFR Part 99 and Part 300 to withdraw your consent at any time. You are not required to enroll in Medicaid. Billing Medicaid will not require you to incur any out-of-pocket expenses such as a deductible or co-pay, decrease lifetime coverage, increase premiums or lead to the discontinuation of benefits, or result in you paying for services that would other wise be covered by Medicaid. No matter whether you grant consent, refuse consent, or revoke your consent, your child will still be provided with an evaluation and/or the services listed in their IEP at no cost to you.

For a more detailed explanation of Medicaid Parental Consent, please see the following Code of Federal Regulations (CFR).

34 CFR 300.154

34 CFR 300.503

34 CFR 300.622

34 CFR 99.30

For specific questions regarding the Medicaid School Program Parental Consent, please contact Health Process Consulting, Inc. at 1-866-625-2003; or Northridge Schools, 2251 Timber Lane, Dayton, Ohio, at 937-278-5885.

Northridge Local Schools

Educating Today for Tomorrow’s Success

CHILD’S INFORMATION:

CHILD’S NAME ____________________________________________________________________     

DATE OF BIRTH ____/______/____     DISTRICT NAME ___________________________________

Ohio school districts have the opportunity to receive federal Medicaid dollars through a program called the Ohio Medicaid School Program (MSP). Through this program, school districts can receive Medicaid dollars for services identified in the IEP, such as Speech, Audiology, Physical Therapy, Occupational Therapy, Nursing, Psychology, Counseling, and Social Work services. In the process of billing Medicaid for these services, billing information must be shared with the Ohio Department of Medicaid. For Medicaid billing purposes, schools must obtain a one-time signed Parental Consent to Share Health Information for the Ohio School Medicaid Program. After this one-time written consent, you will receive an annual notice of this consent.

Schools request this consent for all students who receive special education services, even students who may not be currently eligible for Medicaid. Some health information shared is specific to your student, while other information is related to all students within the entire school district. Schools can use this health information to help reduce special education costs that the district must deliver pursuant to the Individuals with Disabilities Education Act (IDEA). This student specific health information is protected and will be accessed only by people authorized to do so by the school’s Medicaid contract.

Your consent is voluntary. You have the right to withdraw your consent at any time (34 CFR Part 99 and Part 300.) You are not required to enroll in Medicaid. If your school does bill Medicaid, you will not be required to incur any out-of-pocket expenses such as a deductible or co-pay, decreased lifetime coverage, increased premiums or the discontinuation of benefits, or result in you paying for services. If a bill or Explanation of Benefits (EOB) is received, you are not required to cover any cost for school-based services. 

Regardless of whether you grant consent, refuse consent, or revoke your consent, your child will still be provided with an evaluation and/or the services as identified by the IEP team at no cost to you.

____ I understand and agree to give permission to share my child’s specific health information in order for the school to access Medicaid.

____ I do not give permission to share my child’s specific health information in order for the school to access Medicaid.

Parent (printed) Name ________________________________

Parent Signature _____________________________________

Date ________/_______/______

Please contact Healthcare Process Consulting, Inc. at 1-866-625-2003 or at www.hpcohio.com with questions or if you feel you have incurred a personal cost for these services.

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PR-10 PARENTAL CONSENT TO SHARE HEALTH INFORMATION FOR THE OHIO SCHOOL MEDICAID PROGRAM                                         INITIAL VERSION BY ODE: August 1, 2014                                  Page 1 of 1