Sections and Fields in the IEP 'Insurance Consent' form

The following details are auto-populated in the document.

Student Information

The following table shows details of all the fields that are needed to build a Student Profile.

Field Name	Description	Data Flow	Source
Student	Name of the student for whom the meeting has been called	In	This information is auto-populated based on the student records.
STN	Student Test Number	In	This information is auto-populated based on the student records.
Birth Date	Date of Birth of the student to determine the age	In	This information is auto-populated based on the student records.
School	The name of the school in which the student is currently enrolled	In	This information is auto-populated based on the student records.
Current Grade	The class/grade in which the student is currently enrolled	In	This information is auto-populated based on the student records.

The following table lists all the fields needed to track the authorization of the Medicaid document.

Field Name / Title	Description	Data Flow	Source
The parent will sign a paper copy.	The parent or Guardian has agreed to give consent for claiming Medicaid.	Out	Select the checkbox.
I will not give the consent.	The parent or Guardian has declined to give the content for considering Medicaid.	Out	Select the checkbox.

The following table lists all the fields that are needed to track the process of signing the Medicaid document.

Field Name	Description	Data Flow	Source
Parents or Student’s Name	This is a mandatory field. The parent's name will be added to the document.	Out	Parent name.
Parents / Guardian Signature	Parents will put either a Physical or Digital Signature on the document.	Out	Parents will put either a Physical or Digital Signature on the document.
Date	The date on which the above signatures were put on the document.	Out	Parents will either write the date physically on the document or put the date electronically