Home Medical Referral Form (Page 2 of 2) in pdf

Home Medical Referral Form Page 2

A COPY OF IMMUNIZATION RECORDS ARE REQUIRED WITH THIS REFERRAL

Page 2 of 2

HOME MEDICAL REFERRAL

Student Name ________________________________________

D.O.B __________________________

PHYSICIAN:

A request for temporary Home Instruction has been made for the above‐named student. The California

Education Code §44873 requires that a licensed California physician file a statement which includes a medical diagnosis to

the extent that the student is unable to attend classes on any school campus. Chronic conditions may not qualify.

DO NOT USE THIS FORM FOR PSYCHIATRIC CONDITIONS. (USE ATTACHMENT C).

Attending Physician’s Statement

Is student physically capable of attending classes on his/her school campus now, with

□

accommodations to meet their physical or other needs?

Yes

If yes, please list accommodations:

If no, please complete the information below:

Diagnosis:

Summary of Therapeutic Plan to enable the

student to return to school:

Limitations, restrictions, or precautions the

teacher should take in teaching this

student:

□

Is student’s condition contagious?

Yes

I estimate this student will be homebound until (Specific date required): _______________________

Physician’s Signature ______________________________M.D.

Date________________________

Physician’s Name (Print) _______________________________ M.D. Phone: (

) __________________

Fax: (

) __________________

Address____________________________________ City______________________ Zip ______________

C:/Documents and Settings/lauds_user/Desktop/REFERRALS

Home Medical Referral Form Page 2