SCCS Student Insurance Collection Form

Insurance can now support Counseling & other services at schools at no cost to families through the California Youth Behavioral Health Initiative (CYBHI). PLEASE CONSIDER FILLING OUT - Completing this helps our schools to maintain counseling and mental health services!

Important details for families:

  • All info is Confidential. All information about your child is protected under HIPAA and FERPA regulations.
  • There is NO COST to families. These services are free of charge. You will not incur any out-of-pocket expenses, including deductibles or co-pays. These services are covered by Medi-Cal or private insurance, with no co-pays, deductibles, or impact on your insurance benefits.
  • Consent Required: Your consent allows Santa Cruz City Schools to bill Medi-Cal or private insurance for services provided. 
  • No Impact on Benefits: Billing for school-based services will not affect your insurance coverage, policy limits, or private services.
Please complete the form below to consent to participate in this initiative.
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Student Name *
Date of Birth *
School Name *
Grade: *
Do you have medical insurance for your student? *
Insurance Provider Name
Policy Number
Group Number
Insured Parent/Guardian Name
Student's Date of Enrollment in the plan
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/
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/
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