I as parent/guardian of my child give permission to the public agency (school district, municipality or Medicaid provider) to use Medicaid to pay for IFSP services and to such public agency and to each approved private special education school or provider who provides IFSP services to my child to disclose information regarding diagnosis and procedure codes for billing Medicaid for services described in their IFSP ad for evaluation in relation to the services; and in the event of an audit, documentation required to support services reimbursement by Medicaid from my child’s educational records to local, state and federal agency representatives for the sole purpose of claiming Medicaid reimbursement for covered health-related support services for each service and for each school year in which services are provided as recommended in my child’s IFSP if they become Medicaid eligible.
I give my consent voluntarily and understand that I may withdraw that consent at any time. I also understand that my child’s entitlement to a free and appropriate public education (FAPE) is in no way dependent on my granting consent.