Request For Medical Information For Section 504 Evaluation

Request For Medical Information For Section 504 Evaluation - Form 504 F Page 2

Please explain how the disability or impairment affects the major life

activity or bodily function:

3. Medical treatment plan (include medications and/or assistive devices): *Attach pages as

necessary.

4. Recommendations or additional comments: *Attach pages as necessary.

________________________________________________________

_____________

Signature of Physician/Health Care Provider

Date

________________________________________________________

Printed Name

Please return to:

________________________________ __________________________ _________________

Name

Title

School

_____________________________________________________________________________

Address

_____________________________________ _____________________________

Telephone Number

Fax number

Directions for Case Manager: While a medical diagnosis is not required to support the existence of a Section 504

disability, information about an existing medical diagnosis may be helpful to the evaluation and eligibility process.

You may use this form to seek information from the health care provider with the parent’s consent (see Consent for

Release of Information – Form 504 E). Seeking the medical information does not prevent the evaluation process

from continuing.

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Form 504F, Page 2

Request For Medical Information For Section 504 Evaluation - Form 504 F Page 2