Utah schools and child nutrition sponsors use this statement when a child needs special meals, an accommodation or a milk substitution for a medical reason. The licensed medical authority states the condition, describes the major life activities or bodily functions affected, lists foods and beverages to exclude and substitute, and notes texture changes or adaptive equipment. The parent signs a consent that lets staff discuss and follow the diet order.
A licensed medical authority completes items 7 through 15 and signs with credentials; in Utah that includes MDs, DOs, PAs, APRNs, naturopathic physicians and registered dietitians. The parent or guardian completes the site and child details and signs the consent.
Download the current version from the source each time; forms change without notice.
Medical Statement to Request Special Meals, Accommodations, Milk Substitutions
Declaración médica para solicitar comidas especiales, adaptaciones, sustitutos de leche
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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Anyone authorized to write a medical prescription in Utah: medical doctors, osteopathic physicians, physician assistants, advanced practice registered nurses, naturopathic physicians (ND or NMD) and registered dietitians (RD or RDN). For programs in Bureau of Indian Education schools, the Indian Health Service requires a DEA license.
Yes. The Utah State Board of Education posts English and Spanish versions, both revised October 2024, on its National School Lunch Program page, along with a Medical Authority Checklist for foods to exclude and substitute in both languages.
By signing, the parent lets the institution's staff discuss the child's dietary accommodations and follow the prescribed diet order for meals. It also allows the child's medical authority to clarify the diet order on the form if institution personnel ask.