Medical Diagnosis(es) Confirmation Template
Utah Department of Health & Human Services
School Year:
504 Date:
IEP Date
(if applicable):
Picture
STUDENT INFORMATION
Student: DOB: Grade: School:
Parent: Phone: Email:
Physician: Phone: Fax or Email:
School Nurse: School Phone: Fax or Email:
Plan Initiated by: Date:
PARENT
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:
HEALTHCARE PROVIDER
As the above named student’s healthcare provider I confirm the student has the following medical
diagnosis(es):
Prescriber Name (print): Phone:
Prescriber Signature: Date:
Katelyn Nielson, RN, BSN