Medicaid Forms

Consent for Medicaid Reimbursement

Parents of students with individualized education plans (IEPs) are asked to fill out The Request for Consent for Medicaid Reimbursement form. The Medicaid Consent Form and the Annual Notification Letter can be printed out in all nine of the New York City Department of Education (NYCDOE) languages for parents in your school to fill out and return to you.

Engaging Families

What is the purpose of the Medicaid consent form?

The NYCDOE can receive additional funding for some of the services that are provided to students with IEPs. In order for our schools to receive this funding, the NYCDOE needs a consent form signed by the student’s parent or guardian that allows the NYCDOE to submit a reimbursement claim to Medicaid.

Who signs the consent form?

The NYCDOE asks all parents and guardians of students with Individualized Education Programs (IEPs) to sign the form, regardless of their Medicaid eligibility. The NYCDOE must provide students with the services on their IEP regardless if there is a signed consent form. Schools and related service providers are never made aware of a family’s Medicaid eligibility. 

How often does the form need to be signed?

A consent form only needs to be signed and returned once to the NYCDOE. The form will be valid for the current year and future school years.

How does the form get distributed and collected?

In prior school years the consent form was printed by schools and sent home with students for parents or guardians to sign and return to the school. The NYCDOE has expanded this practice, and asks staff to print and collect the forms when a parent or guardian is on site. For example, if a student’s parent is at a school for an IEP meeting, we ask that a member of the IEP review team print the form from Automate the Schools (ATS), ask the parent to sign the form, and scan the signed form back into ATS.

Why does the form need to be printed from ATS?

When a student’s form is printed from ATS it prints with a bar code that allows for simple electronic storage of both the form and the parent’s response.

What if I do not have access to ATS?

If you do not have access to ATS, please work with your school secretary, who can access the MEDL screen in ATS to print out a customized student form. The school secretary can also access the RSEM screen to determine the current consent status of a student and if a form needs to be printed, signed, and collected.

Who should print the form and ask the parent/guardian to sign?

All staff that interact with the parents or guardians of students with IEPs are asked to assist in this process. This includes:

  • Parent Coordinators 
  • IEP Review Team Members
  • Principals and Assistant Principals  
  • Related Service Providers

Collecting consent forms

As in past practice, the distribution and collection of the forms remains an item on the principals’ compliance checklist. School principals are responsible for having the forms collected and returned to the school, with a compliance checklist deadline of mid-December.

Questions Families Ask

Can I change my mind after I have signed a consent form?

Yes. You can change your mind at any point. Contact your child’s school and ask that they print a new Medicaid consent form for your child. You can fill that new form out and return it to your child’s school.

My family is not Medicaid eligible—do I need to complete the form?

The NYCDOE asks all families of students with IEPs to complete this form, regardless of their Medicaid eligibility status. The form does not ask a family to identify their Medicaid eligibility status.

Will signing the form impact my family’s Medicaid benefits? Are there any costs to me or my family?

No. Signing the form will not impact a family’s Medicaid benefits. There is no cost to you or your family. There are no expenses, premiums, costs, or co-payments. If your family receives Medicaid benefits, your coverage will not be canceled, the lifetime coverage in place will not decrease, and services that your family receives will not be affected in any way by the accessing of Medicaid benefits. You will not risk the loss of eligibility for home and community-based waivers, if any, that are based on your total health-related expenditures.

Will my child’s Individualized Education Plan (IEP) related services be impacted if I do not sign the form?

No. The consent form has no impact on service provision to your child. The NYCDOE is obligated to provide the services on the IEP regardless of whether or not there is a signed Medicaid Consent Form. You will not be asked to sign up for or enroll in Medicaid for your child to receive the services on his/her IEP.

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