Florida schools in the USDA meal programs use this statement when a child's physical or mental impairment restricts their diet and the needed meal falls outside the standard meal pattern. A parent asks the clinician to complete Section B and returns the signed form to the school. It applies to school lunch and breakfast, afterschool snacks, summer meals served through the school lunch program, the Special Milk Program and the Fresh Fruit and Vegetable Program.
The parent or guardian completes Section A (items 1 to 9), including a HIPAA and FERPA release naming the clinician and school district. The child's recognized medical authority completes Section B (items 10 to 20); the form lists MD, DO, PA, APRN or registered dietitian, while FDACS guidance describes a Florida-licensed professional who can write prescriptions.
The parent enters the child's name, birth date and their own contact details, then signs a HIPAA and FERPA authorization naming the child's recognized medical authority and the school district, so the clinician and school can exchange the information on the form. The parent may refuse the authorization without affecting eligibility for the special diet.
Check whether the child has a physical or mental impairment that restricts the diet. If yes, describe in detail how it restricts the diet and which major life activity is affected. The instructions give examples such as a peanut allergy that causes a life-threatening reaction, or diabetes that requires timed meals with insulin.
Explain the diet or meal modification the child needs, such as all foods in liquid or pureed form, and attach a specific diet or meal plan if needed. For caloric changes or a liquid nutritive formula, FDACS guidance says additional detail is needed, so give portions or specifications here.
List the specific foods to omit and the foods to substitute, for example exclude fluid milk and include calcium-fortified milk. Skip it if no foods need to be omitted. USDA requires the statement to include foods to be omitted and recommended alternatives when appropriate, and school food service staff may not interpret, revise or change a diet order.
Check the food texture and liquid consistency needed using the IDDSI levels printed on the form: Regular, Easy to Chew, Soft and Bite-sized, Minced and Moist, Pureed or Liquidized for food, and Thin through Extremely Thick for liquids. Skip this item if no texture change is needed.
List any adaptive equipment or specialty utensils the child needs to eat, such as a sippy cup, a large-handled spoon or a suction plate. Add any other information about eating or feeding patterns that will help the school provide the modification.
Print your name and phone number, sign, and date the statement. Item 20 is the office stamp, completed by your staff with the practice name and contact details. The school uses the boxes below the stamp to record copies sent to the cafeteria or food service management company, the 504 committee and the school nurse, and filing in student records.
Download the current version from the source each time; forms change without notice.
Medical Statement for Meal Modifications in School Nutrition Programs
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.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Section B names the child's doctor (MD or DO), physician assistant, advanced practice registered nurse or registered dietitian. FDACS guidance and the form's own flow chart describe the recognized medical authority as a Florida-licensed health care professional authorized to write prescriptions, so check with the school district if a dietitian's signature alone is in question.
No. FDACS guidance says updated medical statements are not required each year. When the family reports new medical information, the school must make sure the statement on file reflects the child's current needs, and any change to the diet order must be in writing on a new signed statement.
Yes. FDACS publishes a Spanish version, the Declaración médica para modificaciones, alongside the English form. A separate English and Spanish statement exists for the Summer Food Service Program, and FDACS also offers a form for discontinuing a meal modification request.
Not under USDA rules when the meal stays within the meal pattern, such as chopped, ground or pureed versions of the regular menu. FDACS recommends obtaining one anyway, and districts may require it. Item 13 uses IDDSI levels, from Regular (7) to Liquidized (3) for food and Thin (0) to Extremely Thick (4) for liquids.