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.

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?*

Yes (e.g. Medi-Cal, Private Insurance, or any other Health Insurance)No Insurance

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

Dependent #1 - Insurance ID Number*

e.g., AB12345C

Dependent #1 - Group Number (if applicable)

Leave blank if your insurance card does not list Group ID number

Dependent #1 - Policy Holder's Full Name*

First NameLast Name

Dependent #1 - FRONT of insurance card image

pdf, doc, jpg, jpeg, png

Dependent #1 - BACK of insurance card image

pdf, doc, jpg, jpeg, png

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

YesNo

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?*

Yes (e.g. Medi-Cal, Private Insurance, or any other Health Insurance)No Insurance

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

Dependent #2 - Insurance ID Number*

e.g., AB12345C

Dependent #2 - Group Number (if applicable)

Leave blank if your insurance card does not list Group ID number

Dependent #2 - Policy Holder's Full Name*

First NameLast Name

Dependent #2 - FRONT of insurance card image

pdf, doc, jpg, jpeg, png

Dependent #2 - BACK of insurance card image

pdf, doc, jpg, jpeg, png

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

YesNo

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?*

Yes (e.g. Medi-Cal, Private Insurance, or any other Health Insurance)No Insurance

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

Dependent #3 - Insurance ID Number*

e.g., AB12345C

Dependent #3 - Group Number (if applicable)

Leave blank if your insurance card does not list Group ID number

Dependent #3 - Policy Holder's Full Name*

First NameLast Name

Dependent #3 - FRONT of insurance card image

pdf, doc, jpg, jpeg, png

Dependent #3 - BACK of insurance card image

pdf, doc, jpg, jpeg, png

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

YesNo

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?*

Yes (e.g. Medi-Cal, Private Insurance, or any other Health Insurance)No Insurance

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

Dependent #4 - Insurance ID Number*

e.g., AB12345C

Dependent #4 - Group Number (if applicable)

Leave blank if your insurance card does not list Group ID number

Dependent #4 - Policy Holder's Full Name*

First NameLast Name

Dependent #4 - FRONT of insurance card image

pdf, doc, jpg, jpeg, png

Dependent #4 - BACK of insurance card image

pdf, doc, jpg, jpeg, png

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

YesNo

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?*

Yes (e.g. Medi-Cal, Private Insurance, or any other Health Insurance)No Insurance

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

Dependent #5 - Insurance ID Number*

e.g., AB12345C

Dependent #5 - Group Number (if applicable)

Leave blank if your insurance card does not list Group ID number

Dependent #5 - Policy Holder's Full Name*

First NameLast Name

Dependent #5 - FRONT of insurance card image

pdf, doc, jpg, jpeg, png

Dependent #5 - BACK of insurance card image

pdf, doc, jpg, jpeg, png

As part of the Children and Youth Behavioral Health Initiative (CYBHI), our school district is asking families to share their 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. Chula Vista Elementary School District is committed to supporting the well-being of all students by providing social-emotional learning (SEL). Support may include classroom SEL lessons, behavior support, self-regulation strategies, counseling services as appropriate, and other related services designed to help students navigate personal, social, and emotional 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. The school will not charge co-pays or deductibles for any care your student gets through us.

I consent to allow Chula Vista Elementary School District to bill my child's health insurance plan for services provided to my child under the Children and Youth Behavioral Health Initiative (CYBHI). I understand that I will not be personally billed for any services my child receives at school. I understand that if my child is or may become eligible for services under CYBHI, I authorize Chula Vista Elementary School District to release student information for the limited purposes of billing health insurance plans and to access health insurance for applicable services. This will not affect any insurance benefits I currently have or may receive. I understand that this information will be used solely for billing purposes and remain confidential under the Family Educational Rights and Privacy Act (FERPA) and/or the Health Insurance Portability and Accountability Act (HIPAA) where applicable.

I acknowledge that my consent applies solely to the services offered by Chula Vista Elementary School District, its designated providers and/or affiliated provider. I am aware that I can change my decision at any time and opt out of receiving services from Chula Vista Elementary School District, its designated providers and/or affiliated provider. If I choose to do so, I will inform Chula Vista Elementary School District in writing by sending a letter to the address provided on my designated school’s website or by emailing the Student Services Department. I understand that this consent form remains effective until Chula Vista Elementary School District receives a written revocation.

I consent to continue allowing my student(s) to receive academic and behavioral health support services.I do not consent. I acknowledge that funds in my students school site may be impacted.

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*

Parent / Guardian Signature*

Date*

Dependent(s) Information

Consent

Parent / Guardian Information