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PDF (28 KB)

Letter to Parents - Autism Funding Attachment

Restriction of Patient Health Information
Regarding Medicaid Autism Services

To assist transitioning to the waiver alternative, we will forward your childís name, your name, and address to your county agency. If you do not want this information to be forwarded, please complete and send this form to the address listed below by July 15, 2003. By sending this form, you are stating that you DO NOT wish to have your child receive continued in-home autism services that will be provided under the waiver alternative beginning in the fall.

I hereby do not authorize disclosure of the named individualís health information to my county human services agency.

________________________________________   __________________________
Patient First  Middle Last    Date of Birth
________________________________________ __________________________
Medicaid Card Number    Home Phone Number
Signature of Parent or Legal Guardian   Date


Mail this form by July 15, 2003, to:

Alan White
Bureau of Program Integrity
P. O. Box 309
1 W. Wilson Street
Madison, WI 53701-0309