Consent Requirements for Students with Medical Assistance Only
The annual written consent to bill Medical Assistance (MA) or MinnesotaCare is no longer required.
However, a Release of Information is required one time. Use the HSRM-52 form below to obtain a signature from the parent/legal guardian when an IEP health related service is documented in the IEP for the first time.

• Place the white copy in the special education IEP folder.


• Place the yellow copy of the form in the building folder used by the compliance assistants. The compliance assistants will bring this form to 360 Billing Office.


• Give the families the Notice of Procedural Safeguards brochure. You may download the latest version from this site.(See below).


• Annual Notification must be given to the parent, or legal guardian. After the initial signature is received, annual Notification will be sent out from the billing office to the parent, or legal guardian. This annual notification must include:
        1. The district's intent to seek reimbursement from medical Assistance for individual education health related services;
        2. The right of the parent or legal representative to request a copy of all records concerning individual education plan health related service disclosed by the district to any third party;
        3. The right of the parent or legal representative to withdraw consent for disclosure of a child's records at any time without consequence.