"Medical Statement for Meal Modifications in Child and Adult Care Food Program (CACFP) Adult Day Care Centers" - Connecticut

Medical Statement for Meal Modifications in Child and Adult Care Food Program (CACFP) Adult Day Care Centers is a legal document that was released by the Connecticut State Department of Education - a government authority operating within Connecticut.

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Medical Statement for Meal Modifications in Child and
Adult Care Food Program (CACFP) Adult Day Care Centers
This form applies to requests for meal modifications for adult participants in adult day care centers participating in the U.S.
Department of Agriculture’s (USDA) CACFP. CACFP adult day care centers are required to make reasonable meal
modifications for participants whose physical or mental impairment restricts their diet. For guidance on meal modifications
and instructions for completing this form, see the Connecticut State Department of Education’s (CSDE) document,
Guidance
and Instructions: Medical Statement for Meal Modifications in CACFP Adult Day Care
Centers.
Note: The USDA requires that the medical statement includes: 1) information about the participant’s physical or mental
impairment that is sufficient to allow the adult day care center to understand how the impairment restricts the participant’s
diet; 2) an explanation of what must be done to accommodate the participant’s disability; and 3) if appropriate, the food or
foods to be omitted and recommended alternatives. CACFP adult day care centers should not deny or delay a requested
meal modification because the medical statement does not provide sufficient information. When necessary, the adult
day care center should work with the participant or responsible family member to obtain the required information. While
obtaining additional information, the CACFP adult day care center should follow the portion of the medical statement that is
clear and unambiguous to the greatest extent possible.
Section A – Completed by participant or responsible family member
1. Name of participant:
2. Birth date:
3. Name of responsible family member (if applicable):
4. Phone number (with area code):
5. E-mail address:
6. Address:
City:
State:
Zip:
7. In accordance with the provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the
Family Educational Rights and Privacy Act (FERPA), I hereby authorize
name of participant’s recognized medical authority
to release such protected health information as is necessary for the specific purpose of special diet information to
and I consent to allow the recognized medical authority to freely
name of CACFP adult day care center
freely exchange the information listed on this form and in my records with the adult day care program as necessary. I
understand that I may refuse to sign this authorization without impact on the eligibility of my request for a special diet. I
understand that I may rescind permission to release this information at any time except when the information has already
been released.
8. Signature of participant or responsible family member:
9. Date:
Section B – Completed by participant’s recognized medical authority
This section must be completed by the participant’s physician, physician assistant, doctor of osteopathy, or advanced practice
registered nurse (APRN). APRNs include nurse practitioners, clinical nurse specialists, and certified nurse anesthetists who are
licensed as APRNs.
10. Physical or mental impairment: Does the participant have a physical or mental impairment that restricts the participant’s diet?
No
Yes: Describe how the participant’s physical or mental impairment restricts the participant’s diet.
11. Diet plan: Explain the meal modification for the participant. Attach a specific diet plan, if needed.
Connecticut State Department of Education  Revised July 2019  Page 1 of 2
Medical Statement for Meal Modifications in Child and
Adult Care Food Program (CACFP) Adult Day Care Centers
This form applies to requests for meal modifications for adult participants in adult day care centers participating in the U.S.
Department of Agriculture’s (USDA) CACFP. CACFP adult day care centers are required to make reasonable meal
modifications for participants whose physical or mental impairment restricts their diet. For guidance on meal modifications
and instructions for completing this form, see the Connecticut State Department of Education’s (CSDE) document,
Guidance
and Instructions: Medical Statement for Meal Modifications in CACFP Adult Day Care
Centers.
Note: The USDA requires that the medical statement includes: 1) information about the participant’s physical or mental
impairment that is sufficient to allow the adult day care center to understand how the impairment restricts the participant’s
diet; 2) an explanation of what must be done to accommodate the participant’s disability; and 3) if appropriate, the food or
foods to be omitted and recommended alternatives. CACFP adult day care centers should not deny or delay a requested
meal modification because the medical statement does not provide sufficient information. When necessary, the adult
day care center should work with the participant or responsible family member to obtain the required information. While
obtaining additional information, the CACFP adult day care center should follow the portion of the medical statement that is
clear and unambiguous to the greatest extent possible.
Section A – Completed by participant or responsible family member
1. Name of participant:
2. Birth date:
3. Name of responsible family member (if applicable):
4. Phone number (with area code):
5. E-mail address:
6. Address:
City:
State:
Zip:
7. In accordance with the provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the
Family Educational Rights and Privacy Act (FERPA), I hereby authorize
name of participant’s recognized medical authority
to release such protected health information as is necessary for the specific purpose of special diet information to
and I consent to allow the recognized medical authority to freely
name of CACFP adult day care center
freely exchange the information listed on this form and in my records with the adult day care program as necessary. I
understand that I may refuse to sign this authorization without impact on the eligibility of my request for a special diet. I
understand that I may rescind permission to release this information at any time except when the information has already
been released.
8. Signature of participant or responsible family member:
9. Date:
Section B – Completed by participant’s recognized medical authority
This section must be completed by the participant’s physician, physician assistant, doctor of osteopathy, or advanced practice
registered nurse (APRN). APRNs include nurse practitioners, clinical nurse specialists, and certified nurse anesthetists who are
licensed as APRNs.
10. Physical or mental impairment: Does the participant have a physical or mental impairment that restricts the participant’s diet?
No
Yes: Describe how the participant’s physical or mental impairment restricts the participant’s diet.
11. Diet plan: Explain the meal modification for the participant. Attach a specific diet plan, if needed.
Connecticut State Department of Education  Revised July 2019  Page 1 of 2
Medical Statement for Meal Modifications in CACFP Adult Day Care Centers
Section B – Completed by participant’s recognized medical authority, continued
12. Food omissions and substitutions: List foods to be omitted from the participant’s diet and foods to be substituted.
13. Food texture: List foods that require a change in texture. Indicate “all” if all foods should be prepared in this manner.
 Cut up or chopped into bite-size pieces:
 Finely ground:
 Pureed:
14. Equipment: List any special equipment or utensils needed.
15. Additional information: Indicate any other information about the participant’s eating or feeding patterns that will assist in
providing the requested meal modification.
16. Name of recognized
17. Phone number
medical authority:
(with area code):
18. Signature of recognized medical authority:
19. Date:
20. Office stamp:
This form is available at
https://portal.ct.gov/-/media/SDE/Nutrition/CACFP/SpecDiet/AdultMedical.pdf.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations
The Connecticut State Department of Education is
and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering
committed to a policy of equal opportunity/affirmative
USDA programs are prohibited from discriminating based on race,
action for all qualified persons. The Connecticut
color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or
Department of Education does not discriminate in any
activity conducted or funded by USDA.
employment practice, education program, or educational
activity on the basis of age, ancestry, color, criminal record
Persons with disabilities who require alternative means of communication for program information (e.g. Braille,
(in state employment and licensing), gender identity or
large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they
expression, genetic information, intellectual disability,
applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA
learning disability, marital status, mental disability (past or
through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available
present), national origin, physical disability (including
in languages other than English.
blindness), race, religious creed, retaliation for previously
opposed discrimination or coercion, sex (pregnancy or
To file a program complaint of discrimination, complete the
USDA Program Discrimination Complaint
Form,
sexual harassment), sexual orientation, veteran status or
(AD-3027) found online at:
How to File a
Complaint, and at any USDA office, or write a letter addressed to
workplace hazards to reproductive systems, unless there is
USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint
a bona fide occupational qualification excluding persons in
form, call (866) 632-9992. Submit your completed form or letter to USDA by:
any of the aforementioned protected classes.
(1)
mail: U.S. Department of Agriculture
Inquiries regarding the Connecticut State Department of
Office of the Assistant Secretary for Civil Rights
Education’s nondiscrimination policies should be directed
1400 Independence Avenue, SW
to: Levy Gillespie, Equal Employment Opportunity
Washington, D.C. 20250-9410;
Director/Americans with Disabilities Coordinator (ADA),
(2)
fax: (202) 690-7442; or
Connecticut State Department of Education, 450
(3)
email:
program.intake@usda.gov.
Columbus Boulevard, Suite 607, Hartford, CT 06103, 860-
807-2071, levy.gillespie@ct.gov.
This institution is an equal opportunity provider.
Connecticut State Department of Education  Revised July 2019  Page 2 of 2
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