The Parent Consent Form asks the parent/guardian permission (consent) to bill your or your child’s Medicaid Insurance Program for any special education and related services that are on your child’s Individualized Education Program (IEP). This consent allows Dutchess County Preschool Special Education Program or your school district to bill for covered health related services such as Occupational Therapy, Physical Therapy, Speech Therapy, or Counseling and Training and to release information to the County or school district’s Medicaid Billing Agent for that purpose.
Complete and submit the Parent Consent Form for Accessing a Parent or Student's Medicaid Insurance to Pay for Certain Special Education Services in a Student's Individualized Education Program (IEP).
If you do not wish to complete the form online, you may download a printable version of the form (English .pdf).
Download/Print: Written Notification Regarding Use of Public Benefits or Insurance to Pay for Certain Special Education and Related Services (.pdf)
Si no desea completar el formulario en línea, puede descargar una versión del formulario para imprimir (Spanish .pdf).
Descargar/Imprimir: Notificación por Escrito Sobre el Uso de Beneficios Públicos o Seguros para Pagar Cierta Educación Especial y Servicios Relacionados (.pdf)