Get Medical Request For Home Instruction Form

Chancellor s Regulation A-170 Attachment No. 2 Page 1 of 1 MEDICAL REQUEST FOR HOME INSTRUCTION TO BE COMPLETED BY TREATING PHYSICIAN is under my care for Student s Name/DOB Diagnosis OR Student s Child s Name What limitations does this diagnosis cause e.g. severely limits ambulation How does this limitation affect the student s ability to attend school e.g. increases risk of fractures. Expected duration of the limitation number of weeks Additional Comments please attach additional sheets as needed I request home instruction to be provided for weeks minimum of 4 weeks Hours of instruction 5 hours per week for Grades K-6 and 10 hours per week for Grades 7-12. I can be reached at Tel. Mon. hrs Tues. hrs Wed. hrs Thur. hrs Fri. Provider s Original Signature License Print Name/Degree Date PARENT CONSENT FOR RELEASE OF MEDICAL INFORMATION Please complete the attached Authorization for Release of Health Information Pursuant to HIPPA. I can be reached at Tel. Mon. hrs Tues. hrs Wed. hrs Thur. hrs Fri. Provider s Original Signature License Print Name/Degree Date PARENT CONSENT FOR RELEASE OF MEDICAL INFORMATION Please complete the attached Authorization for Release of Health Information Pursuant to HIPPA. This form is necessary in the event additional information is required from your physician to approve the request for Home Instruction. FOR SCHOOL USE ONLY Student s Name DOB ID Address All referrals should be sent to the appropriate borough office below EXCEPT for psychiatric referrals. Expected duration of the limitation number of weeks Additional Comments please attach additional sheets as needed I request home instruction to be provided for weeks minimum of 4 weeks Hours of instruction 5 hours per week for Grades K-6 and 10 hours per week for Grades 7-12. I can be reached at Tel* Mon* hrs Tues. hrs Wed* hrs Thur. hrs Fri. Provider s Original Signature License Print Name/Degree Date PARENT CONSENT FOR RELEASE OF MEDICAL INFORMATION Please complete the attached Authorization for Release of Health Information Pursuant to HIPPA. This form is necessary in the event additional information is required from your physician to approve the request for Home Instruction* FOR SCHOOL USE ONLY Student s Name DOB ID Address All referrals should be sent to the appropriate borough office below EXCEPT for psychiatric referrals. c/o P. 754X Room 114 470 Jackson Avenue Bronx NY 10455 P 718 742-0972 F 718 742-1792 c/o P. 371K Annex Site 360 36th Street Room 301 Brooklyn NY 11232 P 718 499-0636 F 718 499-2305 c/o P. 752Q Room 228 142-10 Linden Boulevard Jamaica NY 11436 P 718 529-0266 F 718 529-0292 c/o P. 721M Room 212 250 W* Houston Street New York NY 10014 P 646 486-3557 PSYCHIATRIC REFERRALS ONLY should be sent to 3450 E* Tremont Ave. N*Y. 10465 P 718 794-7200 F 718 794-7232 155 Tompkins Avenue Staten Island NY 10304 P 718 447-4447 F 718 447-0837. This form is necessary in the event additional information is required from your physician to approve the request for Home Instruction* FOR SCHOOL USE ONLY Student s Name DOB ID Address All referrals should be sent to the appropriate borough office below EXCEPT for psychiatric referrals. c/o P. 754X Room 114 470 Jackson Avenue Bronx NY 10455 P 718 742-0972 F 718 742-1792 c/o P. 371K Annex Site 360 36th Street Room 301 Brooklyn NY 11232 P 718 499-0636 F 718 499-2305 c/o P.