Parental Consent to
Access Public Benefits (Medicaid)
The Ohio Medicaid
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
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
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 Pamela Thompson, Director of Special Education, Northridge Schools, 2251 Timber Lane, Dayton, Ohio, at 937-278-5885 or [email protected]
Northridge Local Schools
Educating Today for Tomorrow’s Success
CHILD’S NAME ____________________________________________________________________
OF BIRTH ____/______/____ DISTRICT
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.
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.
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.
(printed) Name ________________________________
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.
PARENTAL CONSENT TO SHARE HEALTH INFORMATION FOR THE OHIO SCHOOL MEDICAID
VERSION BY ODE: August 1, 2014 Page 1 of 1
Help Locate Children with Disabilities (Child Find Notice)
In accordance with rule 3301-51-03 of the Operating Standards for Ohio’s Schools Serving Children with Disabilities, Northridge Local School District participates in an on-going effort to identify, locate, and evaluate all children aged three through twenty-one with disabilities residing within the district, including children with disabilities who are homeless, are wards of the state, or who are attending nonpublic schools located within Northridge Local School District, regardless of the severity of their disability.
A child is considered to be a child with a disability under rule 3301-51-03 if they have a cognitive disability (mental retardation), hearing impairment (including deafness), visual impairment (including blindness), a speech or language impairment, an emotional disturbance, an orthopedic impairment, autism, traumatic brain injury, other health impairment, specific learning disability, deaf-blindness, developmental delay, or multiple disabilities.Some parents may not be aware of the programs and services that are available. If you suspect your child has a disability or if you know of a child who you suspect may have a disability, or if you have questions about special education for children with disabilities, please contact the Special Education Department by calling (937) 278-5885.
Additional information about child find obligations and special education in general may be found in Whose IDEA is This? A Parent’s Guide to the Individuals with Disabilities Education Improvement Act of 2004 (IDEA) available by contacting the Special Education Department.
Required Notices: Special Education Preschool Program
Information about Early and Periodic Screening Diagnostic and Treatment (EPSDT).
Children enrolled in Medicaid are required to participate in this program, school districts must provide information to all families about the program described below:
Healthchek Services for Children Younger than Age 21
Healthchek is Ohio's Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program. It is a service package for babies, kids, and young adults younger than age 21 who are enrolled on Ohio Medicaid.
The purpose of Healthchek is to discover and treat health problems early. If a potential health problem is found, further diagnosis and treatment are covered by Medicaid.
Healthchek covers ten check-ups in the first two years of life and annual check-ups thereafter and offers a comprehensive physical examination that includes:
• medical history
• complete unclothed exam (with parent approval)
• developmental screening (to assess if child's physical and mental abilities are age appropriate)
• vision screening
• dental screening
• hearing assessment
• immunization assessment (making sure child receives them on time)
• lead screening; and
• other services or screenings as needed
If your children are enrolled on Ohio Medicaid, Healthchek services are available to them. If you are younger than age 21 and are also enrolled, you can receive Healthchek services, too.
For more information:
• Read the Healthchek and Pregnancy Related Services Information Sheet: English (Instructions), en Español or Somali.
• Read about Frequently Asked Questions
If you still have questions about Healthchek, send us a note through the Healthchek Questions form.
Information about HELP ME GROW
For programs serving infants and toddlers, schools must provide families information regarding the Individuals with Disabilities Education Act (IDEA), Part C Assessments and Screenings. This information is for early intervention services for infants and toddlers.
In Ohio, the County Board is the primary contact for an individual and their family. TheCounty Board Main Office contact information is as follows: 5450 Salem Avenue Dayton OH 454261450 phone: (937) 837-9200 fax: (937) 854-0492.
The County Board serves two primary functions:
Determining Eligibility: Your County Board will work with you to determine eligibility for services. Eligibility criteria varies by age:
• Ages 0-2: the eligibility report completed by or for Help Me Grow is used to determine eligibility.
• Ages 3-5: Each County Board sets eligibility requirements, which may include the evaluation completed by or for the school district for preschool special education
• Ages 6+: Standard assessment tools are used to measures an individual's current functional abilities in life activity areas – mobility, self-care, self-direction, capacity for independent living, learning, and receptive and expressive language skills – for ages 16 and older, the tool also measures economic self-sufficiency. To be eligible for services, an individual must show substantial functional limitations in at least three of these areas. The tools used are the Children's Ohio Eligibility Determination Instrument (COEDI) for children ages 6-15, and the Ohio Eligibility Determination Instrument (OEDI) for individuals ages 16 and older. If you'd like to learn more about these tools, you can review these documents used to administer the assessments.
Service Coordination: Once you are eligible for services, your County Board will link you to needed services and supports. A Services and Support Administrator (SSA) will work with you to develop an Individual Service Plan that outlines what types of supports are needed.
When to contact your local County Board
Contact your local County Board:
• If your child is diagnosed with a developmental disability, or you suspect your child may have a developmental disability.
• If additional support is needed to achieve your/your child's goals.
• If you are moving to a new community and are receiving services, and want to continue receiving services once you move.
Case Management (Service and Support Administration - SSA)
Case management is a process to link individuals and families to needed services and supports provided by local county boards of DODD. It may include any or all of the following supports:
• Information, referral and linkage
• Eligibility determination and assessment
• Individual Service Plan development and revision
• Assistance in provider selection and accessing services
• Coordination and monitoring of services
• Quality assurance of services provided to individuals and families
• Crisis intervention
Jon Peterson & Autism Scholarship:
This letter is to inform you that your child may be eligible for a scholarship under the Autism Scholarship Program or the Jon Peterson Special Needs Scholarship Program to attend a special education program that implements the child's individualized education program and that is operated by an alternative public provider or by a registered private provider.
Below you will find further information regarding contact information at the Ohio Department of Education if you should need to make inquiries regarding these scholarship programs.
Autism Scholarship Program Website: click HERE!
Jon Peterson Special Needs Scholarship Website: click HERE!
For more information on these scholarship programs, contact the Quality School Choice and Funding Department with the Ohio Department of Education at:
Phone: (614) 466-5743
Toll Free: (877) 644-6338
Director, Special Education
Eye Exam Form Information:
The Amended Substitute House Bill 95 passed in 2003 requires students initially
identified with disabilities to have an eye exam beginning in the fall of 2004. This
exam is very important since most learning is through vision. An eye exam
performed by an eye doctor, optometrist or ophthalmologist can detect vision
problems. The appointment with the eye doctor should be made within 90 days after
your child is initially identified with disabilities. If your child has had an eye exam
within the previous nine months, the requirement is waived.
An estimated 85% of students already have some form of insurance that will cover
the eye exam. However, if you do not have coverage and cost is an issue, you may
contact the Ohio Optometric Association for assistance. Their number is 1-614-781-
0708. A list of eye doctors by zip code can be accessed at www.ooa.org.
Once the eye exam has been completed, please send the report to your building's
Thank you for attending to this need.
Northridge Special Education Department