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California Department of Education Nutrition Services Division Child Nutrition Programs CNP925 (Rev. 08/15) Page 1 MEDICAL STATEMENT TO REQUEST SPECIAL MEALS AND/OR ACCOMMODATIONS 1. School/Agency

How to fill out medical statement to request

How to fill out a medical statement to request:

1. Start by providing your personal information, including your name, contact details, and date of birth. This information is essential for identification purposes.
2. Next, mention the purpose of the medical statement request. Clearly state why you need the medical statement and the specific details or documentation you are seeking.
3. Specify the medical conditions or symptoms that necessitate the request. Be concise and provide any relevant medical history or diagnosis that supports your need for the statement.
4. Include any additional information or supporting documents that might strengthen your case. This could include test results, medical reports, or notes from healthcare professionals.
5. Sign and date the medical statement to certify that the information provided is accurate and complete. If necessary, include the contact information of a healthcare professional who can verify the details mentioned in the statement.

Who needs a medical statement to request:

1. Individuals applying for disability benefits may require a medical statement to support their claim. This statement can provide evidence of their medical condition and its impact on their ability to work.
2. Students requiring accommodations in educational settings, such as extended time on exams or special classroom arrangements, may need a medical statement to request such accommodations.
3. Individuals seeking medical leave or accommodations in the workplace due to a medical condition may also need a medical statement to substantiate their request.

In summary, filling out a medical statement to request involves providing personal information, specifying the purpose of the request, detailing the medical conditions, and including any supporting documents. Various individuals, such as those applying for disability benefits, students needing educational accommodations, or employees seeking workplace accommodations, may need a medical statement to support their requests.

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