Medical Diagnosis(es) Confirmation Template

Utah Department of Health & Human Services

School Year:

504 Date:

IEP Date

(if applicable):



Student: DOB: Grade: School:

Parent: Phone: Email:

Physician: Phone: Fax or Email:

School Nurse: School Phone: Fax or Email:

Plan Initiated by: Date:


As parent/guardian of the above named student I give permission for communication between my

student’s health care provider and the school nurse if necessary for planning the care while my student is in

school. I understand that the information contained in any resulting healthcare plan will be shared with

school staff on a need-to-know basis and that it is the responsibility of the parent/guardian to notify school

staff whenever there is any change in the student’s health status or care.

Parent Name (print): Signature: Date:


As the above named student’s healthcare provider I confirm the student has the following medical


Prescriber Name (print): Phone:

Prescriber Signature: Date:

Katelyn Nielson, RN, BSN This email address is being protected from spambots. You need JavaScript enabled to view it.

pdfMedical Diagnosis