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Medical Statement for Food Substitutions & Modifications School Year 202223 This form is to be used when requesting food substitutions or modifications. USDA Regulation 7 CFR Part 15b requires substitutions
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How to fill out special dietary needs medical

01
Obtain a special dietary needs form from your doctor or healthcare provider.
02
Fill out all required personal information, including your name, date of birth, and contact information.
03
Indicate any food allergies or intolerances you have, as well as any dietary restrictions.
04
Provide details about any medications you are currently taking that may impact your diet.
05
Sign and date the form, and return it to your doctor or healthcare provider for review.

Who needs special dietary needs medical?

01
Individuals with specific food allergies or intolerances.
02
People with certain medical conditions that require dietary restrictions, such as diabetes or celiac disease.
03
Patients on medications that may interact with certain foods or nutrients.
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Special dietary needs medical is a form used to document and address specific dietary requirements for individuals with medical conditions or health concerns.
Individuals with medical conditions or health concerns that require special dietary accommodations are required to file special dietary needs medical.
Special dietary needs medical can be filled out by providing detailed information about the individual's medical condition, dietary restrictions, and required accommodations.
The purpose of special dietary needs medical is to ensure that individuals with medical conditions receive the necessary dietary accommodations to support their health and well-being.
Information such as the individual's medical condition, specific dietary restrictions, recommended dietary modifications, and any other relevant health information must be reported on special dietary needs medical.
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