Chatham Central School District
Committee on Special Education
50 Woodbridge Avenue
Chatham, NY 12037
(518) 392-1540

July 1, 2022

This form has been adapted from the U.S. Department of Education’s model Notification Form 1.

INTRODUCTION

You are receiving this written notification to give you information about your rights and protections under the federal Individuals with Disabilities Education Act (IDEA), so that you can make an informed decision about whether you should give your written consent to allow your school district/county to use your or your child’s public benefits or insurance to pay for special education and related services that your school district is required to provide at no cost to you and your child under IDEA.

Funds from a public benefits or insurance program (for example, Medicaid funds) may be used by your school district (or, for preschool students, the county) to help pay for special education and related services, but only if you choose to provide your consent, as explained below.

Before your school district or county can ask you to provide consent to check with the New York State Department of Health whether your child has public benefits or insurance (e.g., Medicaid coverage and/or a Client Identification Number (CIN)), and to access these benefits or insurance for the first time, it must provide you with this notification of the rights and protections available to you under IDEA. This notification is intended to help you understand these rights and protections, including the type of consent your school district will ask you to provide. Whether or not you provide consent, your school district has a continuing responsibility to ensure that your child is provided all required special education and related services under IDEA at no charge to you or your child.

PARENTAL CONSENT
34 CFR §300.154(d)(2)(iv)(A)-(B) and 8 NYCRR §200.5(b)(8)(i)

Before your school district (or for preschool students, your county) can use your or your child’s public benefits or insurance for the first time to pay for special education and related services under IDEA, it must obtain your signed and dated written consent. Your school district is only required to obtain your consent one time.

This consent requirement has two parts.
For the full Suggested Model for Written Notification of Parental Rights regarding Use of Public Benefits or Insurance
developed by the U.S. Department of Education, see: http://www2.ed.gov/policy/speced/guid/idea/memosdcltrs/accmodelwrittennotification-6-11-13.pdf

1. Consent to share records about your child: Your school district is required to obtain your written consent before disclosing (sharing) personally identifiable information about your child (such as
   your child’s name, address, social security number, individualized education program (IEP), and evaluation results) from your child’s education records. In asking for your consent, the school
   district will (1) identify the records (or information) about your child that will need to be shared (for example, about the services that may be provided to your child); (2) tell you the purpose of
   sharing the records (for example, billing for special education and related services); and (3) identify the agency to which your school district may disclose the information (for example, the
   Medicaid agency).

2. Consent to check with the New York State Department of Health whether your child has a CIN/public benefits or insurance (Medicaid) coverage, and bill your child’s public benefits or insurance (Medicaid) program: Your consent must include a statement specifying that you understand and agree that your school district or county, for preschool, may use you or your child’s public benefits or insurance (e.g., Medicaid) to pay for some of your child’s special education services. You have the right to withdraw your consent at any time. If you withdraw your consent, the school district
   must still provide all of your child’s IEP special education and related services at no cost to you. To withdraw your consent, you will need to submit your request in writing to your child’s school district.

NO COST PROVISIONS
34 CFR §300.154(d)(2)(i)-(iii) and 8 NYCRR §200.5(b)(8)(ii)(b)-(d)

The IDEA “no cost” protections regarding the use of public benefits or insurance are as follows:

1. Your school district may not require you to sign up for or enroll in a public benefits or insurance program in order for your child to receive a free appropriate public education.

2. Your school district may not require you to pay any out-of-pocket expenses, such as the payment of a deductible or co-pay amount for filing a claim for services that your school district is otherwise required to provide your child without charge.

3. Your school district may not use your or your child’s public benefits or insurance if using those benefits or insurance would:
   a. decrease your available lifetime coverage or any other insured benefit, such as a decrease in your plan’s allowable number of physical therapy sessions available to your child or a decrease in your plan’s allowable number of sessions for mental health services;
   b. cause you to pay for services that would otherwise be covered by your public benefits or insurance program because your child also requires those services outside of the time your child is in school;
   c. increase your premium or lead to the cancellation of your public benefits or insurance; or
   d. cause you to risk the loss of your child’s eligibility for home and community-based waivers that are based on your total health-related expenditures.

We hope this information is helpful to you in making an informed decision regarding whether to allow your school district or county, for the provision of preschool special education, to use your or your child’s public benefits or insurance to pay for special education and related services under IDEA. Contact information: For additional information and guidance on the requirements governing the use of public benefits or insurance to pay for special education and related services see:
https://www2.ed.gov/policy/speced/reg/idea/part-b/part-b-parental-consent.html