Anchorage School District
District
Annual Written Notification and Medicaid Consent
Anchorage School District (ASD) students and families must provide a one-time consent to ASD for ASD to access Medicaid reimbursement for eligible services provided to students. Additionally, ASD must provide an Annual Written Notification to students and their families, informing them of their Medicaid rights as they apply to ASD's School-Based Medicaid program. Beginning with the 2023/2024 school year, ASD provides these documents with student enrollment and registration forms for all ASD students. These documents are available below for viewing and download in English, Hmong, Korean, Samoan, Spanish, and Tagalog. Contact the ASD School-Based Medicaid office to request translations into another language, or to have a hardcopy document mailed to your home.
ASD SBS Medicaid Forms
English Medicaid Annual Written Notification PDF
English Medicaid Consent Form PDF
Hmong Medicaid Annual Written Notification PDF
Hmong Medicaid Consent Form PDF
Korean Medicaid Annual Written Notification PDF
Korean Medicaid Consent Form PDF
Samoan Medicaid Annual Written Notification PDF
Samoan Medicaid Consent Form PDF
Spanish Medicaid Annual Written Notification
Spanish Medicaid Consent Form PDF
Tagalog Medicaid Annual Written Notification
Tagalog Medicaid Consent Form PDF
ASD SBS Medicaid Revocation Form Fillable
This document can be used to revoke Medicaid consent after it has been granted to ASD. Please complete and sign the form then return it to the ASD SBS Medicaid office by email or mail.