- Created 03/16
- Reviewed 11/23
- When making a request for child records, the staff member is to complete a Request Letter (DISA 2f, DISA 2g, FS/PE 4d, MH 5b, HLTH 11e1a-11e2).
- Guidance on filling out Request for Health Documentation Letter
- Check ChildPlus.net health module for date of most recent request if made.
- When sending the request letter (DISA 2f, DISA 2g, FS/PE 4d, MH 5b, HLTH 11e1) please make sure each field LOC ID, Child’s Name, Parent/Guardian Name, Clinic Name and Request line are completed and that your request for information is as specific as possible before sending to the Program Coordinator/Assistant for processing.
- Please do not date the request form. Due to Office Staff workload, there could be a delay in processing the request. Office staff will enter the date that the request is processed and entered into ChildPlus.
- If the student is on a seizure, anaphylaxis, dietary accommodation or asthma action
plan:
- The primary care provider must be the one to complete the action plan.
- Obtain the name of the primary care provider or provider who established the action plan for the child and fax number of local clinic.
- Place the provider’s name and fax number on record’s request.
- The following are examples of the language to be used when requesting records:
- Milk Allergy (HLTH 11e1e) – If requesting a milk substitute that is NOT Lactose Free Milk or Soymilk – List what type of milk child is allergic to and request treatment plan and/or special dietary accommodations. (Review procedure NUTR 1k.) Staff will assist the parent in completing the TOP SECTION ONLY of the Dietary Accommodations Form. The staff member will then send in the original copy of the Special Dietary Accommodation Form to the Health Coordinator or Health Specialist to have it faxed or mailed to the child’s health care provider to complete, sign, and date the Diet Order section of the form.
- Food Allergy (HLTH 11e1d) – Review procedure NUTR 1k, section III prior to attaching and completing the Request for Special Dietary Accommodations form. Staff will assist the parent in completing the TOP SECTION ONLY of the Dietary Accommodations Form. The staff member will then send in the original copy of the Special Dietary Accommodation Form to the Health Coordinator or Health Specialist to have it faxed or mailed to the child’s health care provider to complete, sign, and date the Diet Order section of the form and return it to the Head Start Health Specialist.
- Anaphylaxis Allergies other than Food Allergies and Medications (HLTH 11e1k) – If requesting verification of anaphylaxis of anaphylaxis, please include medication
list and anaphylaxis action plan.
Note: These are often included in physical/WCE if we are aware of the condition prior to requesting records. However, if not, we will request verification separately. - Asthma (HLTH 11e1f) – Verification of asthma, please include medication list and asthma action plan.
Note: These are often included in physical/WCE if we are aware of the condition prior to requesting records. However, if not, we will request verification separately. - Dental Exams (HLTH 11e1b) – Most recent dental exam records (include date, if known).
- Dental Treatments (HLTH 11e1b) – Most recent dental treatment (include date, if known).
- Developmental (DISA 2f or DISA 2g) – Parent consent for evaluation, evaluation summary, IEP or IFSP meeting invitation and IEP or IFSP records.
- Hearing (HLTH 11e1) – Most recent hearing exam, treatment plan and recommendations (include date, if known).
- DCYF (CPS) (FS/PE 4d) – Current engagement in services, assigned social worker and contact information, family goal, and other/recommended strategies to support family success and stability.
- Physical Exam/WCE (HLTH 11e1a) – Most recent Phys/WCE, including Ht/Wt, Immunizations, Hct/Hgb, Lead Screening and UA (include date of exam in your Request Letter, if known). EHS Staff: Please also include “most recent OAE hearing screening date and results” in your request.
- Sick Visit (HLTH 11e1) – Most recent sick visit, diagnosis, recommendations and follow-up if needed (include date, if known). *Sometimes the child visits the Emergency Room. At this time, you would request ER visit.
- Seizure Action Plan (HLTH 11e11) – Most recent sick visit, diagnosis, recommendations and follow-up if needed (include date, if known). *Sometimes the child visits the Emergency Room. At this time, you would request ER visit.
- Mental Health (MH 5b) – Current enrollment in services, assigned clinician and contact information, intake summary/diagnosis, Psychiatric/Psychological Evaluation Assessments, Medication Management Plan, Treatment Plan (most recent), Clinical/Therapy Progress Notes, Exit/Discharge Summary, Other/Recommended strategies to support student in education setting.
- Vision (HLTH 11e1c) – Most recent vision exam, treatment plan and recommendations (include date, if known).
- WIC (HLTH 11e1c) – Most recent office visit, including Ht/Wt, Hgb/Hct and recommendations (include date, if known).
- Guidance on filling out Request for Health Documentation Letter
- The DST/EHS staff member is to enter the request into ChildPlus Family Services if a Head Start/EHS/Prenatal student or the Health section of ELMS if an ECEAP student.
- Send the completed Request Letter (DISA 2f, DISA 2g, MH 5b, HLTH 11e1a-11e2) to the Program Coordinator/Assistant. If the Parent/Guardian Permission to Reveal or Obtain Confidential Information form (ERSEA
1d) for the provider is new, attach the original to the letter. The Program Coordinator/Assistant
will database into the health module of ChildPlus.net; initial and date bottom corner
of original ROI; scan and attach the original ROI into the enrollment module of ChildPlus.net;
and send the original to the DST. The Program Coordinator/Assistant will coordinate
the requesting of documentation.
When sending in a letter of request, staff will print a copy of the pertinent ROI from the database and attached to the request. - Prior to faxing or mailing the letter with a copy of the release to the provider, the Program Coordinator/Assistant will write the date and his/her initials on the letter.
- 5. If the letter is to be mailed, the Program Coordinator/Assistant will make a copy of it.
- The Program Coordinator/Assistant will fax or mail the letter with a copy of the release to the provider.
- The Program Coordinator/Assistant will enter request information onto the ChildPlus/Health Database; note this has been done on the original letter (if faxed) or on the copy of the letter (if mailed) and then forward the documentation to the DST/EHS Staff for placement in the child’s Site file.