Common use of Validate Clause in Contracts

Validate. Complete the information below. _ Signature of validating school employee _ Date (mm/dd/yyyy) _ Printed name of validating school employee _ _ Name of school or school district Toledo Public Schools Parent Consent to Share Information and Access Public Benefits Ohio School Districts havethe opportunity to receive Federal Medicaid dollars through a program called the Ohio Medicaid School Program (OMSP). Throughthisimportant program, all Ohio schooldistricts can receive critically necessary Medicaid dollars to help support the special education type services provided to its students, such as Speech/ language, Audiology, Physical Therapy. Occupational Therapy, Nursing, Psychology, Counseling and Social Work. In the process of billing Medicaid for these services, a limited amount of billing information must be shared with the Ohio Department of Medicaid. To do so, we must obtain a one-time/life signed Parental Consent to share the followingNON-MEDICALinformation: Yourchild's name, Medicaidrecipient number, and birth date Servicecode (numericalcodethatidentifies (theservice(s) provided) Service time spent with your child (number of minutes) Your consent is voluntary. You have the right under Federal Medicaid Regulations (34 CFR Part 99 and Part 300) to withdraw your consent at any time. You are never required to enroll in Medicaid for your child to receive special education services in this or any other Ohio Public School District. No matter whether you grant, refuse or revoke consent, your child will be provided with all evaluation and/or the services listed in their IEP, AT NO COST·to your family. The School District's Medicaid billing process will not require you to incur any out-of- pocket expenses such as deductible or co-pay, decrease lifetime coverage, increase premiums or lead to the discontinuation of benefits, or result in you paying for services that would otherwise be covered by Medicaid. If you have questions regarding this form please call ▇▇▇-▇▇▇-▇▇▇▇. Student Name: Dateof Birth: I understand and agree to give permission to share my child's IEP records in order to access Medicaid. I do not give my permission to share my child's lEP records in orderfor the School Medicaid funding. District to receive Parent/Guardian Printed Name: Parent/Guardian Signature: Date: � Return completed form to: Student Services DISTRICT-WIDE ELEMENTARY DRESS CODE

Validate. Complete the information below. _ Signature of validating school employee _ Date (mm/dd/yyyy) _ Printed name of validating school employee _ _ Name of school or school district Toledo Public Schools Parent Consent to Share Information and Access Public Benefits Ohio School Districts havethe have the opportunity to receive Federal Medicaid dollars through a program called the Ohio Medicaid School Program (OMSP). Throughthisimportant Through this important program, all Ohio schooldistricts school districts can receive critically necessary Medicaid dollars to help support the special education type services provided to its students, such as Speech/ language, Audiology, Physical Therapy. , Occupational Therapy, Nursing, Psychology, Counseling and Social Work. In the process of billing Medicaid for these services, a limited amount of billing information must be shared with the Ohio Department of Medicaid. To do so, we must obtain a one-time/life signed Parental Consent to share the followingNON-following NON- MEDICALinformation: Yourchild▇▇▇▇▇▇▇▇▇'s name, Medicaidrecipient Medicaid recipient number, and birth date Servicecode (numericalcodethatidentifies (theservice(sbirthdate Servicecode(numericalcodethatidentifies(heservice(s) provided) Service time spent with your child (number of minutes) Your consent is voluntary. You have the right under Federal Medicaid Regulations (34 CFR Part 99 and Part 300) to withdraw your consent at any time. You are never required to enroll in Medicaid for your child to receive special education services in this or any other Ohio Public School District. No matter whether you grant, refuse or revoke consent, your child will be provided with all evaluation and/or the services listed in their IEP, AT NO COST·to COST to your family. The School District's Medicaid billing process will not require you to incur any out-of- of-pocket expenses such as deductible or co-pay, decrease lifetime coverage, increase premiums or lead to the discontinuation of benefits, or result in you paying for services that would otherwise be covered by Medicaid. If you have questions regarding this form please call ▇▇▇-▇▇▇-▇▇▇▇. Student Name: Dateof Date of Birth: I understand and agree to give permission to share my child's IEP records in order to access Medicaid. I do not give my permission mypermission to share my childmychild's lEP IEP records in orderfor order for the School Medicaid funding. District to receive Medicaidfunding. Parent/Guardian Printed Name: Parent/Guardian Signature: Date: � Return completed form toORIGINAL: Student Services Cumulative File SCAN COPY TO: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇.▇▇▇ DISTRICT-WIDE ELEMENTARY DRESS CODE