• Written annual Consent to bill is required from the parent, or legal guardian on an annual basis.
• Use the Consent Form (HSRM-51) below if the family has a Combination of Medical Assistance and Private Insurance. Use the "back of consent.doc" to provide further information to the parent, or legal guardian. This is a two part form. Be sure to use both documents when providing information to parents, or legal guardians.
• After the parent, or legal guardian, has signed this form, 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.
  

Consent Form (HSRM-51, 06-06-02) - Combination of Medical Assistance and Private Insurance, or Private Insurance Exclusively (two page form),
Use Of This Form