Medicaid Release Form
This is a parental, FERPA, and HIPPA consent form designed to inform you and request your permission for your student’s Medicaid insurance information. The purpose of this form is to determine eligibility with Medicaid for JAG KY’s billing purposes for services provided.
Pursuant to law, we will not release any personally identifiable information without prior written consent from you as parent or guardian. Personally identifiable information includes student names, insurance identification number, residential addresses, e-mail address, and phone numbers. If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time.
By signing this form, you consent to our use and disclosure of your personal information to Medicaid for eligibility and billing purposes You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

1. Educational evaluation and program planning
2. Assessment and planning for JAG KY competencies in school.
3. To determine Medicaid eligibility for JAG KY program

By signing this form, I understand that:

• I give consent to JAG KY to obtain my student’s Medicaid Insurance information for the purpose of Eligibility
• and Billing for Medicaid services provided by JAG KY
• JAG KY reserves the right to change the privacy policy as allowed by law.
• JAG KY has the right to restrict the use of the information, but JAG KY does not have to agree to those
• restrictions.
• I have the right to revoke this consent in writing at any time and all full disclosures will then cease.
• This authorization is valid for one calendar year. It will expire one year from the date provided below.
• I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal
of my consent.
• I recognize that health records, once received by the school district, may not be protected by the HIPAA
Privacy Rule, but will become education records protected by the Family Educational Rights and Privacy Act.
• I understand that if I refuse to sign, such refusal will not interfere with my child’s ability to obtain health care.

Email address *
Do you agree to the terms listed above *
First and last name
What is your student's full name? *
Your answer
What is your student's date of birth? *
Your answer
What school does your student attend? *
Your answer
What type of Medicaid Insurance does your student have? *
What is your student's Medicaid Subscriber/Member ID? *
Your answer
This consent was signed by: (please print your first and last name) *
Your answer
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