Special Education Services
Hastings School District #200
1000 West 11th Street, Hastings MN 55033
Consent to Share Data and Seek Payment for Individualized Family Service Plan
(IFSP) /Individualized Education Program (IEP) Health-Related Services
Student’s Name: _______________________________________DOB: ________________
Introduction
If your child receives special education and has Medical Assistance (MA) or MinnesotaCare, Minnesota law requires school districts to seek
reimbursement from insurers and similar third parties for Individualized Education Program (IEP) health related services. Billable services may
include assessments/evaluations, speech/language/hearing services, occupational therapy, physical therapy, nursing services, mental health
services, personal care services, assistive technology devices, interpreter services, and special transportation. Payment sources include Medical
Assistance (MA), MinnesotaCare, and private health insurance.
Notification
This is your annual notification that Hastings School District will be billing Medical Assistance or MinnesotaCare directly, for the health-related
services your child receives, if you have provided consent and have not revoked or denied in writing that consent. The type, amount and frequency
of services are in your child’s IFSP/IEP. The information includes your child’s name, date of birth, member number, dates of service and type of
service codes. If audited by the Department of Human Services (DHS) or the U.S. Department of Health and Human Services (DHHS), the data
shared may include, but not be limited to, your child’s IFSP or IEP, evaluation reports, documentation of service, attendance, and medical orders.
The District must obtain your consent to share data with DHS and to seek reimbursement for health related services. The Minnesota Department
of Education (MDE) has indicated that consent may be obtained through the school district consent form, or the Minnesota Health Care Program
(MHCP) enrollment/re-enrollment form for medical assistance or MinnesotaCare.
I understand:
This is a release to share data with DHS and DHHS and it is good as long as my child is eligible for special education.
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I can change or stop this release in writing at any time. Revocation is not retroactive.
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There will be no cost to my family and this will not affect my MA or MinnesotaCare coverage or other public benefits in any way.
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The type, amount and frequency of services are in my child’s IFSP/IEP.
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If I ask, I can get copies of all data shared with DHS or DHHS.
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I can get a copy of this release.
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Except as allowed by law, these records may not be re-disclosed without my authorization.
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If I do not give information or do not agree to share data with DHS and DHHS, my child’s IFSP/IEP services will not change or stop.
If your child also has Private Health Insurance and MA or MinnesotaCare:
Hastings School District will NOT bill your private insurance. We will receive a state wide denial from the Minnesota Department of Education
(MDE) or your insurance company before billing MA/MinnesotaCare.
I understand:
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The district will use my private health insurance information to determine whether or not my private insurance covers the IFSP/IEP
health-related services that my child receives.
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If the private insurance does not cover the IFSP/IEP health related services my child receives, the school district can bill MA or
MinnesotaCare.
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For parents of children with an IFSP: I have received a copy of the state system of payments policy, which includes: (1) Consent to Share
Data and Seek Payment for IFSP Health Related Services; and (2) Written Annual Notice Related to Third Party Billing for IFSP Health
Related Services. This policy will be provided to me each time my consent is required. If you have questions, you may call 651-480-7016.
Consent for Reimbursement and Release of Records:
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I agree that Hastings Public Schools may access my child’s Medical Assistance or MinnesotaCare for reimbursement of IEP health related services.
I agree Hastings Public Schools may share my child’s information with DHS to determine eligibility, to bill DHS and receive direct payment for IFSP/ IEP
Health-Related Services from MA or MC or to DHS or DHHS if there is an audit.
I understand that, except as allowed by law, these records may not be re-disclosed without my authorization.
This consent starts at the beginning of the school year, including summer school if applicable, and will continue during all periods of eligibility for special
education services.
I have read the Written Annual Notice Related to Third Party Billing for IFSP or IEP Health Related Services on the next page.
Parent/Legal Representative Printed Name: _______________________________________
X________________________________________________________________________
Signature of Parent/Legal Representative (Student if age 18 or older)
______________
Date
Please send to Third Party Billing, Special Services, Hastings School District 200, 1000 West 11th Street, Hastings, MN 55033
10/22/15