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Indiana Special Dietary Needs Medical Statement Form

Indiana schools use this template to collect a request for a meal accommodation for a student with a disability, medical need or impairment, with a parent letter explaining the process. The medical authority states the need, lists foods to omit and substitute, sets food texture and liquid consistency, and explains how the impairment restricts the student's diet.

Who completes it

The parent or guardian fills in the student details and signs. If the student needs a special menu or meal modification, a doctor (MD or DO), NP, PA or registered dietitian prints their name and title and signs.

Submitting and payment

How to submit it
The parent returns the completed form to the accommodations contact named in the school's letter. Staff record when it was received and whether the accommodation fits within the meal pattern.

Good to know

  • Substitutions outside the USDA meal pattern require a signature from a state licensed healthcare professional with prescriptive authority or a registered dietitian.
  • Liquids can be pudding thick, honey or nectar thick, or thinned. Foods can be pureed, diced or finely ground, or chopped into bite-size pieces.
  • An optional HIPAA and FERPA authorization lets school staff speak directly with the medical authority, which the form says may prevent delays.
  • Indiana DOE also posts a Discontinuation of Accommodations Form. USDA rules don't require changes for religious or moral convictions, general health concerns or personal preferences.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Statement Form and Parent Letter

Official pagePDFVersión en español

How this list is checked

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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Frequently asked questions

Is the Indiana school meal medical statement available in Spanish?

Yes. The Indiana Department of Education posts fillable English and Spanish versions on its Special Dietary Needs page, dated January 2025. Both include the parent letter on how to request an accommodation and the household's procedural safeguards through the school's 504 coordinator.

Who can sign Indiana's Special Dietary Needs Medical Statement?

The form asks for a doctor (DO or MD), nurse practitioner, physician assistant or registered dietitian when a student needs a special menu or meal modification. When substitutions fall outside the USDA meal pattern, the signer must be a state licensed healthcare professional with prescriptive authority or a registered dietitian.

What can a family do if Indiana school meal accommodations aren't met?

The parent letter explains that the household can contact the school's 504 coordinator to file a grievance, receive a prompt resolution, request an impartial hearing with counsel, examine the record and appeal the final decision. Parents can also ask for a Section 504 evaluation.