Michigan schools, child care centers and summer meal sites use this form when a child needs meal accommodations for a disability, medical reason or severe allergy in USDA child nutrition programs. The medical provider lists foods to omit and substitute, explains how exposure affects the child, and notes any texture modification or tube feeding. With a disability and a signed statement on file, the sponsor must make the substitutions.
A state-licensed physician (MD or DO), physician assistant, nurse practitioner or APRN, or a registered dietitian completes the dietary accommodation section and signs. The parent or guardian completes the participant information and may sign the voluntary authorization on page 2.
Download the current version from the source each time; forms change without notice.
Special Diet Statement Request Form
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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A state-licensed physician (MD or DO), physician assistant, nurse practitioner or advanced practice registered nurse, or a registered dietitian. The signer prints their name and credentials and adds the clinic or hospital, so the school or center knows whom to contact once the parent authorizes it.
Yes, if it contains all the required information: the food or allergen to avoid, how exposure affects the participant, the foods to substitute, and the signature of a state-licensed healthcare professional. Sponsors may also modify meals while waiting for a correctly completed form.
The Michigan Department of Education offers the Special Diet Statement Request Form and the Dietary Preference Request Form in Arabic, Bengali and Spanish on request from its school nutrition office.