ATLANTA PREPARATORY

Medical Form

Dear Parent/Guardian

If your children qualify for free or reduced price meals, they may also be able to get free or low cost health insurance through Medicaid or the State Childrens's Health Insurance Program (SCHIP). Children with health insutance are more likely to get regular health care and are less likely to become sick

Because health insurance is so important to children's well-being, the law allows us to tell Medicaid and SCHIP that your children are eligible for free or reduced price meals, unless you tell us not to. Medicaid and SCHIP only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children in this health insurance program. Filling out the CACFP Meal Benefit Income Eligibility Forms does not automatically enroll your children in health insurance.

If you do not want us to share your information with Medicaid or SCHIP, fill out the form below and send it with your Income Eligibility Form to [address] by . (Sending in this form will not change whether your children get free or reduced price meals.).

No! I DO NOT want information from my CACFP Meal Benefit shared with Medicaid or the State Children's Health Insurance Program.

Income Eligibility Form Program.
If you checked no, fill out the form below

Child's Name:

Child's Name:

Child's Name:

Child's Name:

Signature of Parent/Guardian:

Today’s Date:

Print Your Name:

Address:

for more inforamtion you may call at
CACFP Meal Benefit Income Eligibility Form Sharing Information with Medicaid/SCHI

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