Healthcare IEP Document

HEALTHCARE INDIVIDUALIZED EDUCATION/HEALTH PLAN (IEP HEALTHCARE COMPONENT)

IDENTIFYING INFORMATION

Patient Name:   Date of Birth:

Phone:   Email:

Relationship:   Phone:

INSURANCE / COVERAGE

Policy/ID Number:   Group Number:

MEDICAL HISTORY & CURRENT STATUS

Asthma    Diabetes    Seizure disorder/epilepsy    Cardiac condition    Other:

HEALTHCARE SERVICES / INTERVENTIONS

Procedure/Service Description:

Medication Name:   Dose/Route:

Schedule:   Administered by:

GOALS, OBJECTIVES, AND OUTCOMES

Initial Plan Date:   Next Scheduled Review:

RISK, BENEFITS, AND CONSENT

The undersigned acknowledges that the prescribed healthcare services are necessary to support the patient's access to educational services. The undersigned has been informed of the nature of the procedures and services described in this plan, the reasonably foreseeable risks and complications, expected benefits, and alternative interventions. The undersigned understands that delegation of certain tasks may be required and that competent school or healthcare staff will be trained and supervised to perform those tasks.

By initialing below, the undersigned grants informed consent for implementation of the medical services, routine monitoring, and emergency interventions set forth in this document, and acknowledges the right to withdraw consent at any time by providing written notice to the responsible healthcare provider or school official.

Consent to Provide Non-Emergent Care: I consent to the provision of the services described in this plan.   Emergency Treatment Authorization: I authorize emergency medical treatment if required.

PRIVACY, RELEASE AND HIPAA AUTHORIZATION

I authorize release of relevant medical and educational information necessary to implement this plan to those school personnel, healthcare providers, and support staff listed in this document. This authorization permits disclosure of protected health information limited to the records and information directly related to the services and goals set forth herein. Information released under this authorization shall be used only to coordinate care, ensure safety and to document services rendered.

Authorization Expiration Date:   If no date provided, this authorization expires at the end of the current academic year.

I understand that I may revoke this authorization at any time in writing except to the extent that action has already been taken in reliance upon it. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations.

DOCUMENTATION AND PROFESSIONAL CERTIFICATION

The undersigned healthcare professional certifies that the information contained in this plan is accurate to the best of their knowledge and that the described interventions are medically necessary for the patient to safely access educational services. Delegation of nursing tasks will be performed in accordance with applicable professional standards and local policy.

Provider Contact:   Date of Certification:

ACKNOWLEDGMENT AND SIGNATURE

By signing below I acknowledge that I have read and understand the contents of this Healthcare IEP Plan, that I have had an opportunity to ask questions and that those questions have been answered. I consent to implementation of the plan as described and to the release of information as stated in the HIPAA Authorization above. I understand I may revoke consent in writing at any time, except to the extent that action has already been taken.

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