STATEMENT OF REASSIGNMENT

______________________________________________________

Name of the Outside Contracted Provider

By this reassignment, the above-named outside contracted provider of services agrees:

1. to reassign all Medicaid reimbursements to your school district that you contracted with

for providing medical services billed under the School Supportive Health Services

Program (SSHSP),

2. to accept as payment in full the contracted reimbursement rates for covered services,

3. to comply with all the rules and policies as described in your contract with the school

district, and

4. to agree not to bill Medicaid directly for any services that the school district will bill for

under the SSHSP program.

NOTE: Nothing in this "Agreement of Reassignment" would prohibit a Medicaid practitioner from claiming reimbursement for Medicaid eligible services rendered outside of the scope of the School Supportive Health Services Program (SSHSP)

________________ _________________________________________________

(Date) (Outside Contract Service Provider's Signature)

_____________________________________________________________________

School District (under contract with): List additional ones on back of this form.)

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