File:  JLCG*-E - Consent to Release Information

(Sample Form)

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 _________ 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 ______________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 Over 18)         Student's Social Security Number

____________________________________    ___________________________

Parent/Guardian Signature (or Student Over 18)    Date

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

COLORADO SAMPLE EXHIBIT 2000