2024-2025 Medicaid Release Form

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Warren Public School's Parental/Guardian Consent to Access Public Insurance and the Release Personally Indentifiable Information

With parental consent, the school district can seek federal Medicaid reimbursement for the cost of the health services the school district provides. This consent grants the school district the ability to release student information for the purpose of billing Medicaid for these services. Information released typically includes the following: student's name, date of birth, and the date and time of the hearing/vision screens conducted in the present school year. You may revoke your consent at any time by notifying the school district in writing.

Is your child covered by Medicaid or ARKids Insurance? *

Yes

Student Full Name *

Student Date of Birth *

YYYY

Grade *

9th

10th

11th

12th

Parent/Guardian Digital Signature *

Today's Date *

YYYY

Submit

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