Nebraska child care centers, day care homes and adult day care sites in the Child and Adult Care Food Program use this statement when a participant needs a meal accommodation that can't be met within federal meal pattern requirements. The health professional describes the impairment that restricts the diet, dietary restrictions, foods to omit and substitute, and texture or thickness changes.
A state licensed health care professional completes and signs it: physician (MD or DO), PA, APRN-NP, registered dietitian or chiropractor. A licensed medical nutrition therapist (LMNT) may sign when working under a licensed physician's consultation.
Download the current version from the source each time; forms change without notice.
Medical Statement (CACFP)
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Yes. Nebraska's form lists physicians (MD or DO), physician assistants, APRN nurse practitioners, registered dietitians and chiropractors as state licensed health care professionals who may complete it. A licensed medical nutrition therapist may also sign when acting under a licensed physician's consultation.
No. This version is specific to the Child and Adult Care Food Program and is listed on NDE's CACFP forms and resources page. It applies to child care centers, day care homes and adult day care, with a Spanish version posted alongside it.