CVESD Insurance Collection

Student Insurance Information

As part of the Children and Youth Behavioral Health Initiative (CYBHI), our school district is asking families to share your child’s medical insurance information. This helps us make sure students can get the care and support they need at school.

Your information is private and protected under all privacy laws, including the Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA).

Sharing this information will not change your child’s insurance or their ability to receive services. You will never be asked to pay anything. The school will not charge co-pays or deductibles for any care your student gets through us.

For more information, please visit our CVESD website:

Chula Vista Elementary School District FAQ

Dependent #1 - Please select the school your student attends

Dependent #1 - Student ID

Dependent #1 - Student Legal Name

First Name + Middle Name (if applicable)Last Name

Dependent #1 - Student Date of Birth

MonthDayYear

Dependent #1 - Does your student have health insurance?

Dependent #1 - Please select the provider name of your student's insurance provider

If other, please specify:

Dependent #1 - Insurance ID Number

e.g., AB12345C

Do you have more students attending Chula Vista Elementary School District?

Dependent #2 - Please select the school your student attends

Dependent #2 - Student ID

Dependent #2 - Student Legal Name

First Name + Middle (if applicable)Last Name(s)

Dependent #2 - Student Date of Birth

MonthDayYear

Dependent #2 - Does your student have health insurance?

Dependent #2 - Please select the provider name of your student's insurance provider

If other, please specify:

Dependent #2 - Insurance ID Number

e.g., AB12345C

Do you have more students attending Chula Vista Elementary School District?

Dependent #3 - Please select the school your student attends

Dependent #3 - Student ID

Dependent #3 - Student Legal Name

First Name + Middle Name (if applicable)Last Name(s)

Dependent #3 - Student Date of Birth

MonthDayYear

Dependent #3 - Does your student have health insurance?

Dependent #3 - Please select the provider name of your student's insurance provider

If other, please specify:

Dependent #3 - Insurance ID Number

e.g., AB12345C

Do you have more students attending Chula Vista Elementary School District?

Dependent #4 - Please select the school your student attends

Dependent #4 - Student ID

Dependent #4 - Student Legal Name

First Name + Middle Name (if applicable)Last Name (s)

Dependent #4 - Student Date of Birth

MonthDayYear

Dependent #4 - Does your student have health insurance?

Dependent #4 - Please select the provider name of your student's insurance provider

If other, please specify:

Dependent #4 - Insurance ID Number

e.g., AB12345C

Do you have more students attending Chula Vista Elementary School District?

Dependent #5 - Please select the school your student attends

Dependent #5 - Student ID

Dependent #5 - Student Legal Name

First Name + Middle Name (if applicable)Last Name(s)

Dependent #5 - Student Date of Birth

MonthDayYear

Dependent #5 - Does your student have health insurance?

Dependent #5 - Please select the provider name of your student's insurance provider

If other, please specify:

Dependent #5 - Insurance ID Number

e.g., AB12345C

As part of the Children and Youth Behavioral Health Initiative (CYBHI), Chula Vista Elementary School District is asking families to share your child's medical insurance information. This helps us make sure students can get the care and support they need at school from their counselors and social workers.

Sharing this information will not change your child's insurance or their ability to receive services. You will never be asked to pay anything. The school will not charge co-pays or deductibles for any care your student gets through us.

Your information is private and protected under all privacy laws, including the Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA).

As part of the Children and Youth Behavioral Health Initiative (CYBHI), Chula Vista Elementary School District is asking families to share your child's medical insurance information. This helps us make sure students can get the care and support they need at school.

I, Parent/Guardian, consent to allow the Chula Vista Elementary School District to provide mental and behavioral health services aimed at enhancing student well-being, skill development, and fostering social support. Support may include classroom SEL lessons, behavior support, self-regulation strategies, counseling services as appropriate, and other related services designed to help students manage social, emotional and personal challenges.

Your information is private and protected under all privacy laws, including the Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA). Sharing this information will not change your child's insurance or their ability to receive services. You will never be asked to pay anything.

I consent to allow Chula Vista Elementary School District to bill my child's health insurance plan for services provided to my child under CYBHI. I understand that I will not be personally billed. I authorize the district to release student information for billing purposes only. All information remains confidential.

I acknowledge that my consent applies solely to services offered by Chula Vista Elementary School District or its designated providers. I may revoke consent at any time by notifying the district in writing.

Information entered on this form will be visible to school district personnel through Healthy Campus.

Parent / Guardian Full Name

First NameLast Name

Parent / Guardian Email

example@example.com

Parent / Guardian Phone

Format: (000) 000-0000.

Parent / Guardian Signature

Date

Dependent(s) Information

Consent

Parent / Guardian Information