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- Click ‘Get Form’ to open the 2011 form medical in the editor.
- Begin by filling out the Demographics/Certification section on page 2. Ensure you provide accurate information about the family member, including their name, date of birth, and any relevant medical history.
- In Item 3, list all active diagnoses for the family member. Use one line per diagnosis and include ICD or DSM designations as required.
- Complete the Medical Summary section starting on page 4. This part must be filled out by a qualified medical professional, detailing treatment plans and prognosis for each diagnosis.
- If applicable, complete any required addenda related to asthma, mental health, or autism spectrum disorders. These addenda should only be filled out if indicated in Item 10 of the main form.
- Review all entries for accuracy before signing. The Parent/Guardian or Person of Majority Age must certify that all information is correct in Item 6 on page 2.
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