Hospital Medical Referral Form
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1A COPY OF IMMUNIZATION RECORDS SHOULD ACCOMPANY THIS REFERRAL
BUL- 1229.2
Page 1 of 1
LOS ANGELES UNIFIED SCHOOL DISTRICT
ATTACHMENT D
Educational Options
Carlson Home Hospital School
December 12, 2011
10952 Whipple St.
No. Hollywood, CA 91602
Phone: (818) 509-8759 FAX: (818) 505-0246
HOSPITAL MEDICAL REFERRAL
CARLSON HOSPITAL TEACHER: ________________________________
____________________________
Print Name
Print Site Name
Patient/Student Information
□
□
Last Name________________________________________ First Name_________________________________
M
F
DOB_________/__________/___________ Gr. ___________ Student Language_________________________
Address ____________________________________________ City______________________________ Zip_______________
Home Phone (
) __________________ Cell Phone (
) ________________ Work Phone (
) __________________
Parent/Guardian ________________________________________ Parent/Guardian Language _________________________
Cum Carrying School ____________________________ Phone (
) _________________ Track ____ Local District _____
Last date of attendance ______________________
□
□
Does student have a current IEP/504 Plan?
Yes
No
Eligibility__________________
IMPLEMENTATION OF SERVICE
HOSPITAL TEACHING - Hospital Instruction will be provided in a manner consistent with California laws governing home/hospital teaching.
Instruction is offered in two (2) basic subject areas unless additional courses are approved by a Carlson administrator.
By signing this authorization for service, the parent/guardian is agreeing to the following:
If the student is eligible, educational services will be temporarily provided by the Carlson Home/Hospital School.
►
The student will be temporarily disenrolled from his/her regular school of attendance (cumulative record carrying school) during the
►
period he/she is receiving home instruction or teleteaching. Grades and marks will be reported to the cumulative record carrying school.
Educational information will be accessed and used to plan and provide an appropriate educational program for the student.
►
Permission to provide services or access school records may be revoked via written parent/guardian request at any time.
►
The parent/guardian has the right to receive a copy of this form upon request.
►
PARENT/LEGAL GUARDIAN AUTHORIZATION TO RECEIVE/RELEASE MEDICAL AND ACADEMIC
INFORMATION AND TEMPORARILY TRANSFER EDUCATIONAL DUTIES:
Parent Signature____________________________________ Date: ___________________
PHYSICIAN: A request for Hospital 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. If educational services are
authorized at this time, please complete, sign below and return this form to the Hospital Teacher or Carlson Office.
Attending Physician’s Statement
Diagnosis or ICD/DSM Code:
Summary of Medical Problem/Therapeutic Plan:
Precautions/Restrictions applicable for bedside/classroom teaching:
Is student in ICU? □Yes □No
In Isolation? □Yes □No
Type ______________________
Is student’s condition contagious? □Yes □No
Admission date:__________________________
Estimated Discharge date:__________________________
Physician’s Signature ______________________________________ M.D.
Date _______________________
Phone: (_____)______________________
Physician’s Name (print) ____________________________________ M.D.
Fax:
(_____)______________________
Address ___________________________________ City __________________________ Zip _______________
C:/Documents and Settings/lauds_user/Desktop/REFERRALS
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