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MASHPEE PUBLIC SCHOOLS <br /> SPECIAL EDUCATION OFFICE <br /> FOR KENNETH C. COOMBS SCHOOL <br /> PARENT/GUARDIAN AUTHORIZATION FOR MEDICAID REIMBURSEMENT <br /> FOR PARENTS/GUARDIANS OF SPECIAL EDUCATION STUDENTS <br /> I, <br /> (please print) <br /> parent/guardian of <br /> (please print) <br /> give permission to Mashpee School District to release information to the Executive Office of <br /> Health and Human Services, the Massachusetts Medicaid Agency,regarding services my child <br /> receives through the Special Education Program. This information is for the sole purpose of <br /> obtaining federal reimbursement to our municipality for the cost of health-related special <br /> education services. <br /> Parent/Guardian Signature Date <br /> Child's Teacher Grade <br /> 64 <br />