Medical Plan Of Care For School Food Service (Page 2 of 2) in pdf

List specific foods to be substituted (Substitution cannot be made unless section is completed):

List foods that need the following change in texture. If all foods need to be prepared in this manner, indicate “All.”

Cut up/chopped into bite sized pieces:

Finely Ground:

Pureed:

List any special equipment or utensils needed:

Indicate any other comments about the child’s eating or feeding patterns:

Physician’s Name and Office Phone Number

Office Stamp

Physician/Medical Authority’s Signature

Date

Part 5: Parent Signature

Date

Part 6: School Nutrition Program Signature

Date

Health Insurance Portability and Accountability Act Waiver

In accordance with the provisions of the Health Insurance Portability and Accountability Act of 1996 and the Family Educational

Rights and Privacy Act, I hereby authorize

_________________________________ (medical authority)

to release such

protected health information of my child as is necessary for the specific purpose of Special Diet information to

_________________________________________ (school/program) and I consent to allow the physician/medical authority to

freely exchange the information listed on this form and in their records concerning my child with the school program as

necessary. I understand that I may refuse to sign this authorization without impact on the eligibility of my request for a special

diet for my child. I understand that permission to release this information may be rescinded at any time except when the

information has already been released. My permission to release this information will expire on __________________

(date).

This information is to be released for the specific purpose of Special Diet information.

The undersigned certifies that he/she is the parent, guardian or representative of the person listed on this document and has the

legal authority to sign on behalf of that person.

Parent/Guardian Signature:________________________________________________

Date:______________________

(Signing this section is optional, but may prevent delays by allowing us to speak with the physician)

Please have parent/guardian review form annually and initial/date if no changes are required. Any changes require submission of

a new form signed by the Physician/Medical Authority.

Parent confirmed no change in diet order. ____ Date ________

____ Date _______

____ Date________

____ Date ________

____

Date_______

A copy of this form should be kept by the School Food Service and the Nurse. FERPA allows school nurses to share

student’s medical information regarding dietary needs with school food service.

Special Dietary Needs

January 2010

Medical Plan Of Care For School Food Service Page 2

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