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san lorenzo medi-cal notice

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San Lorenzo Unified School District
Department of Special Services
15510 Usher Street
San Lorenzo, CA 94580
NOTICE TO PARENTS/GUARDIANS REGARDING MEDI-CAL BILLING
FOR HEALTH SERVICES AND RELEASE OF INFORMATION FOR
MEDI-CAL REIMBURSEMENT
San Lorenzo Unified School District, in cooperation with the Departments of Health Care
Services and Education, is involved with a program that allows for the District to be reimbursed
with federal Medicaid funds for selected health care services (such as hearing and vision
screenings, health assessments, speech services) provided to eligible students attending San
Lorenzo schools. As a student who receives special education services under Part B of the
Individuals with Disabilities Education Act, by giving consent for the District to access MediCal funds (per signed consent on Parent Consent page of IEP), you authorize the District to
release student information to the District’s billing agency, Paradigm Health Care Services, and
the California Department of Health Care Services, for the sole purpose of accessing Medi-Cal
funds for partial reimbursement of eligible health services. Personally identifiable information
(child’s name, birthdate, gender, and information related to the student’s IEP) released is in
accordance to strict confidentiality guidelines with the billing agency and District, and is only
for the purpose of accessing Medi-Cal; the billing agency is HIPPA (Federal Health Insurance
Portability & Accountability Act) compliant.
Your rights are preserved under Title 34 Code of Federal Regulations 300.154; Family
Education Rights Privacy Act of 1974, Title 20 of the United States Code, Section 1232(g),
Title 34 Code of Federal Regulations, Section 99.
You have the right to withdraw your consent for the disclosure of information for these
purposes at any time. If at any time consent is revoked, consent is not retroactive and would not
negate any billing that occurred after consent was originally given and before it was revoked.
Students will not be denied services by the school, and parents will never be billed for services
by the school district. Participation in the program will never impact your health insurance,
and will in no way affect any benefits provided by your health insurance.
If you have any questions or concerns, please contact Thomas Mills, Special Education
Coordinator at 510-317-4770.
January, 2014