SUESD Insurance Collection + Consent to Bill

Student Insurance Information Collection

+ Optional Consent to Seek Reimbursement
What is CYBHI?
The California Children and Youth Behavioral Health Initiative (CYBHI) is a state program designed to expand access to school-based mental and behavioral health supports for students. Through CYBHI, schools can receive reimbursement for counseling and wellness services provided on campus.

What this means for parents and students:
- Parents will not be billed—all costs are covered through state funding and reimbursement.
- The district collects insurance information only so that it can be submitted for reimbursement. This ensures schools are able to sustain and grow student mental health services without creating any financial burden for families.
Cost of Services & CYBHI Billing Information

Under the California Children and Youth Behavioral Health Initiative (CYBHI), SUESD may bill Medi-Cal or commercial insurance for eligible services:
- There is no cost to families. You will not be charged deductibles, co-pays, or fees.
- Billing does not affect your benefits (no reduction of lifetime coverage, no increase in premiums, no loss of eligibility for outside services).
- Billing simply helps the District recoup costs and sustain its counseling program, ensuring long-term access for all students.
- Consent may be revoked at any time. Services will continue regardless of billing consent.
Parent/Guardian Rights
- Your child is entitled to all counseling services at no cost, whether or not you consent to insurance billing.
- Student/family information will only be shared for the limited purpose of billing, in compliance with FERPA and HIPAA.
Students 12 years or older may legally consent to their own counseling services under California law (Ed. Code §49602; Fam. Code §§6924–6929).
STUDENT NAME*

First NameLast Name
SCHOOL OF ATTENDANCE*
STUDENT DATE OF BIRTH*

MonthDayYear
Date
Please select one of the following:*

I authorize SUESD to bill Medi-Cal or my child’s health insurance for eligible services. This consent will not result in any cost to families or impact insurance benefits.I DO NOT authorize SUESD to bill Medi-Cal or my child’s health insurance for eligible services.
By signing this form, I acknowledge that I am providing consent for the Soquel Union Elementary School District to verify eligibility and submit claims to Medi-Cal or private insurance for services provided to my child. I understand that this consent will not result in any cost to me or impact my insurance benefits.
INSURANCE INFORMATION

Please enter your child's insurance information below:
Do you have insurance for this student?*

YesNo
Insurance Provider Name:*
Policy Number:*
Group Number:*
Subscriber Name:*

First NameLast Name
File Upload - Front of Insurance Card

Cancelof
File Upload - Back of Insurance Card

Cancelof
GUARDIAN NAME*

First NameLast Name
PARENT/GUARDIAN SIGNATURE*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Student Insurance Information Collection

INSURANCE INFORMATION