view_day  Section A - IDEA Consent: Parent / Guardian / Surrogate Consent

I/We have had the opportunity to participate in the development of this Individualized Family Service Plan (IFSP) and have been provided reasonable notice of the IFSP meeting.

I/We have been informed of my/our parental rights under this program through receipt of a parents’ rights notice and a family handbook about Maryland’s early intervention system.

The early intervention services will be provided as described in the IFSP. I/We understand that the IFSP will be reviewed at least every six (6) months.

I/We understand that my/our consent is voluntary and that I/we may revoke consent at any time.

I/We understand the records will not be released without my/our signed and written consent except under the provisions of the Family Education Rights and Privacy Act (FERPA). This law allows the release of early intervention records to participating agencies in the early intervention system.

I/We understand that the public agency will submit information through a statewide database. This database will be used by the Maryland State Department of Education (MSDE) and other State agencies, as appropriate, to enable funding of programs.

I/We have been informed of the determination(s) of the IFSP team in my/our native language or other mode of communication.

This plan reflects the outcomes that are important to my/our child and family.

I/We understand the plan and parental rights and give permission to implement this IFSP.

view_day  Section B - Medical Assistance (MA) Consent: Parent / Guardian / Surrogate Consent

Parental consent must be obtained before the provider agency discloses, for billing purposes, their child's personally identifiable information to the Maryland Department of Health and Mental Hygiene (DHMH), the State agency responsible for the administration of the Medical Assistance (MA) Program, consistent with the Family Educational Rights and Privacy Act (FERPA) and the individuals with Disabilities Education Act (IDEA). By providing consent, you understand and agree in writing that the public agency may access your child's Medicaid to pay for services provided to your child.

In order to provide early intervention services to your child, the provider agency may not:

• I/We have been informed of my/our parental rights under this program through receipt of a parents’ rights notice and a family handbook about Maryland’s early intervention system.
• Require you to sign up for or enroll in the State's MA Program in order for your child to receive services under IDEA;
• Use your child's benefits under Medical Assistance if that use would:
  • Decrease available lifetime coverage or any other insured benefit.
  • Result in your family paying for services that would otherwise be covered by Medical Assistance and that are required for your child outside of the time your child is in school.
  • Increase premiums or lead to the discontinuation of benefits or insurances, or
  • Risk loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.

You have the right to withdraw your consent to disclosure of personally identifiable information to State's Medical Assistance Program at any time. If you withdraw consent for the provider agency to disclose your childs's personally identifiable information it does not relieve the provider agency of its responsibility to ensure that all required services are provided to your child at no cost to parent.

I agree to Early Intervention Services Case Management and that the Service Coordinator(s) idenitified on this IFSP may be appointed as MA Service Coordinator(s) (COMAR 10.09.40). I understand that I am free to choose an MA Service Coordinator for my child. At this time, I accept the following Service Coordinator(s):

I understand that if I wish to change the MA Service Coordinator in the future, I can call the early intervention program to make a change.

I understand that the purpose of this service is to assist in gaining access to needed medical, social, educational, and other services.

I give my consent for the provider agency to disclose my child's personality identifiable information to the State's Medical Assistance Program in order to access Medical Assistance Benefits.

I give permission to the provider agency to recover costs from Medicaid for service coordination, as well as health-related services, related to the implementation of my child's IFSP goals.

I understand that if I refuse to allow the provider agency access to MA funds, it does not relieve the provider agency of its responsibility to ensure that all required services are provided to my child at no cost to parent.

I understand that this service does not restrict or otherwise affect my child's eligibility for other MA benefits. I also understand that my child may not receive a similar type of case management under MA if he/she quailifies for more than one type.

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