Medical Statement Resource
The Medical Statement & Letter of Medical Necessity
The medical statement is the means whereby a physician provides relevant medical
information about a child to organizations, agencies, and educational programs that
require such information in order to provide needed services. Examples include child
care, camps, schools, colleges or universities, or health care plans. A medical statement
is most often requested when a child with special health care needs enters a child care
program or school, when an educational team plans accommodations for a child or youth
in an educational setting, when a young adult transitions to a college or university
program, or when a physician requests special medications, services, or equipment
through the health care plan. Medical statements provide information about children and
youth who are in special education with an Individualized Education Plan (IEP), about
individuals who qualify for a 504 plan, and about individuals whose medical condition
requires awareness on the part of a school or organization in case of a medical
emergency. See the Educational Services Resource Page for more information.
What to include in a Medical Statement
A medical statement should include only the information relevant for the participation of
a child or youth in an activity or program. For example, when writing a medical
statement for an IEP, the physician should emphasize the medical information with
implications for the child in school, including relevant diagnoses, medication needs at
school, and functional limitations or needs that may affect the child during the school
day. Much health care information is not relevant to the educational process and should
not be included.
Specific items to include in a medical statement include the following:
- • The relevant diagnosis in medical and laypersons’ terms.
• A brief description of the medical condition if it is not well-known.
• A description of the implications for education
- • A child with acongenital heart condition who fatigues easily will have
limited endurance for a long school day; the limitation on the amount of
time the child should stay actively involved in education should be stated.
•A child with cystic fibrosis will need to visit the school nurse’s office for medications before meals and snacks.
•If the child takes regular medication, the likely side effects of the medication during the school day. For instance, a child on stimulant medication for ADHD may develop tics, over-focusing, or extreme restlessness as the medication wears off in the afternoon.
speech, occupational or physical therapy at the IEP meeting, and make a decision about
which of these services the child will receive at school. Related services must address
goals related to education, such as handwriting, vocational goals or activities of daily
living. The physician can suggest educational goals for related services, but the
physician does not prescribe the therapy that the schools provide. (Some states do require a physician’s prescription for physical or occupational therapy, however, the IEP team decides if it is relevant to the educational process.) Purely medical goals, such as
rehabilitation following knee surgery, are usually not appropriate in an IEP or educational setting.
Since the medical statement conveys individually identifiable health information that is
protected under HIPPA, the physician must ensure that the family knows what information is to be transmitted in the statement, agrees that the physician should share this information, and signs a form authorizing release. After writing a medical statement, physicians usually speak to school personnel with the family’s permission, if school personnel request.
Letter of Medical Necessity
Letters of medical necessity provide information to a health care or health insurance plan
to aid plan administrators when they make a decision about whether to pay for a service.
Generally, requests for durable medical equipment, therapy services aside from those
provided in the school, medications that are not in the routine formulary, and in-home
services require a letter of medical necessity. The use of the term “medical necessity”
may vary from one health care plan to another, but the statement should address at least
one of the following:
- • How the medical condition will improve if the child receives the requested service
• How the child’s ability to care for him/herself will improve
• In what ways the service will facilitate the family’s ability to care for the child
• Why the child’s condition will deteriorate more slowly
• How the equipment, medication, or service replaces or complements current
management
• How the request will be cost effective