Consent For Medicaid School Based Services Page 3
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3Edwardsville Community Unit School District 7
Dr. Ed Hightower, Superintendent
MEDICAID ELIGIBLE FORM
(Complete and return ONLY if student is Medicaid Eligible.)
Student Name: ___________________ ____________________
(First Name)
(Last Name)
Date of Birth: _____ / _____ /_____
(Month)
(Day)
(Year)
Medicaid Number: __ __ __ - __ __ __ - __ __ __
(Attach a copy of the BACK side only of student's
Medicaid Card. Do not copy the front.)
________________________
______________
(Parent/Guardian Signature)
(Date)
For Office Use Only:
Forward this form and a copy of the back of the Medicaid Card to the
Office of Student Services & Special Education
Keep a copy of this form and Medicaid Card in the student's temporary
record.
708 St. Louis Street
618.656.1182
Edwardsville IL 62025
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