Garfield Re-2 Policies

JLCG-E

Consent to Release Information

Colorado school districts are entitled by law to seek Medicaid reimbursement when the districts provide services to Medicaid-eligible students.  The following consent form is to authorize the Garfield Re-2 School District to release to Colorado Health Care Policy and Financing information related to Medicaid services provided to the student identified below as necessary to apply for and recover Medicaid reimbursement.

 

NOTE:  Participation in the school Medicaid reimbursement program does NOT adversely affect the student’s eligibility for future Medicaid services in any way.

 

I give consent and authorize the Garfield Re-2 School District to release to Colorado Health Care Policy and Financing (HCPF) information related to health 

and other Medicaid eligible services the district provides to the student identified below during the __________ school year, as frequently and comprehensively as necessary to apply for and recover Medicaid Partial Reimbursement for such services.

 

 

_____________________________ __________________________

Student Name Student’s Date of Birth

 

_____________________________ ___________________________

Student’s School Student’s Medicaid Number

 

_____________________________ ___________________________

Parent/Guardian Name (or Student Student’s Social Security Number

Over 18)

 

_____________________________ ___________________________

Parent/Guardian Signature (or Student Date

Over 18)

 

If at any time you wish to revoke this permission, please contact _______________.

 

Issued: 1994

 

Garfield School District No. Re-2, Rifle, Colorado