Tools & Forms

Annual Notification and Medicaid Parental Consent

• Medicaid Parental Consent and Annual Notification Checklist (PDF)
• Notice of Parental Rights Concerning the Use of Public Benefits or Insurance (Word)
  • Aviso de los derechos de los padres con repecto al uso de beneficios públicos o seguros - Spanish (Word)
  • Avi sou Dwa Paran Konsènan Itilizasyon Asistans oswa Asirans Piblik - Haitian-Creole (Word)
• Parental Consent Form for Release of Personally Identifiable Information for Medicaid Reimbursement for IEP and Non-IEP Services Combined (PDF)
  • Consentimiento de los padres para divulgar información de identificación personal para el reembolso de Medicaid - Spanish (PDF)
• Parental Consent Form for Release of Personally Identifiable Information for Medicaid Reimbursement (PDF)
  • Consentimiento de los padres para revelar información personal identificable con el fin de obtener el reembolso de Medicaid - Spanish (PDF)
  • Konsantman Paran an bay pou Divilge Enfòmasyon Pèsonèl yo Idantifye pou Ranbousman nan Medicaid la - Hatian-Creole (PDF)
• Parental consent and notification requirements for sharing information related to Medicaid and Private Insurance Billing in Florida Administrative Code-FAC6A-6.03028 (PDF)

Plan of Care