Request Specialized Heath Services Form printable pdf download

Hilliard City Schools

Request for Specialized Health Services

Student:_______________________________________ D.O.B. ______________ Date:____________

Health Care Provider’s Section

Diagnosis and brief history: _____________________________________________________________

_____________________________________________________________________________________

Requested Procedure: __________________________________________________________________

_____ I have reviewed and approved the attached procedural guideline as written.

_____ I have reviewed and approved the attached procedural guideline with the attached modification.

_____ I do not approve of the school’s guideline and therefore have attached an alternative guideline.

Other recommendations (i.e. time, schedule and duration of treatment, special precautions, and

possible complications: _________________________________________________________________

_____________________________________________________________________________________

Procedure to be discontinued or evaluated on this date: _______________________________________

Provider’s Signature:_____________________________________ Phone:________________________

NPI#________________________________ Approved Ohio ORP Provider: Yes/No

Provider’s Address/Office Stamp: _________________________________________________________

Parent/Guardian Section

We (I), the undersigned parent/guardian of the above named student, request that the specialized

health care service outlined above and authorized by my child’s health care provider be provided for our

child. We (I) authorized the school to appoint a qualified designated person(s) to perform the service as

directed. It is our (my) understanding that in performing this service, the designee will be using the

procedure as approved above. I (we) agree to notify school personnel immediately if there is any

change in either the treatment regimen or authorizing health care provider. We (I) understand that the

above service should be scheduled before or after school hours whenever possible.

Parent/Guardian Signature: ____________________________________ Date:____________________

Home phone: __________________ Work: ___________________ Cell:_________________________

School Nurse’s Signature: ___________________________________ Date:_______________________

CC: School, Parent, Provider

2016

Request Specialized Heath Services Form