Dinuba Unified Insurance Collection

Student Insurance Information

As part of the Children and Youth Behavioral Health Initiative (CYBHI), our school district in partnership with the Tulare County Office of Education 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 on California's Children and Youth Behavioral Health Initiative (CYBHI), please see the informational videos available in English and Spanish, or contact your student's school district directly. Thank you for your support and partnership.

Please select the school your student attends

Student ID (optional)

Student Legal Name

First NameLast Name

Student Date of Birth

MonthDayYear

Does your student have health insurance?

Please select the provider name of your student's insurance provider (Primary Insurance)

If other, please specify:

Policy Number

e.g., AB12345C

Policy Holder's Full Name

First NameLast Name

I, the undersigned parent or legal guardian, consent to allow Dinuba Unified School District (DUSD) to provide mental and behavioral health services aimed at enhancing student well-being, skill development, and fostering social support. DUSD is committed to supporting the well-being of all students by offering services that may include individual or group counseling, skill-building sessions, group interventions, and other supports designed to help students navigate personal, social, and emotional challenges.

I further consent to allow DUSD 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 DUSD 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 remains confidential under the Family Educational Rights and Privacy Act (FERPA) and/or the Health Insurance Portability and Accountability Act (HIPAA) where applicable.

This consent applies only to services provided by DUSD, its designated providers, and/or affiliated partners. I understand that I may revoke this consent at any time by submitting a written request to the district at the address or email listed below. Until such revocation is received, this consent remains in effect through the date my child graduates from a school within Dinuba Unified School District.

I am the parent or legal guardian that is legally authorized to make health care decisions or non-emergency medical decisions on behalf of the dependent named in this document. By signing below, I acknowledge that I have been informed of the availability of these services and give permission for my child to participate as needed. These services are provided by qualified professionals to support my child’s overall well-being. If more intensive services
become necessary, I understand I will be contacted and asked to provide additional consent.

Please check all that apply:

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

Parent / Guardian Full Name

First NameLast Name

Relationship to Student

Parent / Guardian Email

example@example.com

Parent / Guardian Phone

Format: (000) 000-0000.

Parent Signature to Consent to Treatment

Date

Parent Signature to Consent to Billing

Date

Dependent Information

Consent

Parent / Guardian Information