Albany City School District
Committee on Special Education
Special Education Department
75 Watervliet Avenue
Albany, NY 12206 (518 475-6150)
Dear Parent/Legal Guardian:
This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance Program for special education and related
services that are on your child's individualized education program (IEP) and to ask you to give us your child’s Client Identification
Number (CIN) or allow us to obtain the CIN if you do not know it.
This consent allows the school district/county to bill Medicaid for covered health-related services and to release information to the
school district’s/county’s Medicaid Billing Agent for that purpose.
I, _________________________________as the parent/guardian of ___________________________________________________,
have received a written notification from the school district/county that explains my federal rights regarding the use of public benefits
or insurance to pay for certain special education and related services.
I understand and agree that the school district/county may ask for a Client Identification Number (CIN), check on Medicaid
eligibility, and/or access Medicaid to pay for special education and related services provided to my child.
I understand that:
Providing consent will not impact my child’s/my Medicaid coverage;
Upon request, I may review copies of records disclosed pursuant to this authorization;
Services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid and/or
provide my child’s CIN;
I have the right to withdraw consent at any time; and
The school district/county must give me annual written notification of my rights regarding this consent.
I also give my consent for the school district/county to release the following records/information about my child to the State’s
Medicaid Agency for the purpose of checking Medicaid eligibility and/or billing for special education and related services that are in
my child’s IEP. The following records will be shared.
Records to be shared (e.g. records or information about services your child receives, student demographic information):
Medication Administration Report
Special Transportation Log
Other Personally Identifiable Information
Any Other Specific Records Pertaining to the Student’s Services
Student’s CIN, if known:
I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to
receive special education and related services is in no way dependent on my granting consent and that, regardless of my decision to
provide this consent, all the required services in my child’s IEP will be provided to my child at no cost to me.
Parent/Guardian Signature: __________________________________________
Print Name: __________________________________________ Date: ____________________