School District U-46 / Homepage
School District U-46Occupational and Physical Therapy Department355 E. Chicago Street, Elgin, IL 60120-6543Tel: 847.888.5000 Ext. 4272Fax: 847.888.5320U- ISO 9001:2008 Certified Quality Management System 102870-44069000-68580-601980Tony Sanders, Chief Executive Officer00Tony Sanders, Chief Executive OfficerParent: Please provide the information requested on the top portion of this form. Forward this form to your child’s doctor for the signature and information requested at the bottom of the form.PLEASE RETURN THE COMPLETED FORM TO THE OT/PT THERAPY OFFICE AT ADDRESS/FAX STATED ABOVE.RELEASE OF STUDENT RECORDSDr. /Professional: _____________________________________ Date: __________________ School Year: ________________Address: ____________________________________________ Student: _____________________________________________City/ State: __________________________________________ Birthdate: ______________________ Grade: ___________Phone: ______________________________________________ Current School: _______________________________________Fax: _________________________________ OT: ____________________________ PT: ________________________________School District U-46 Occupational and/or Physical Therapists have my permission to obtain and/or share medical reports and consultation, evaluations and annual reports, and prescriptions for therapy services. Please be advised that this release will be valid for one year from the date signed.Parent/Guardian: ______________________________________________________________________________________________Address: ____________________________________________________ City/State: _______________________________________ Parent/ Guardian Signature: _____________________________________________________________________________________E-mail: _____________________________________________________ Phone: ___________________________________PHYSICIAN’S ORDERS FOR EDUCATIONALLY BASED OCCUPATIONAL/PHYSICAL THERAPYPlease complete the items below and return to the address or fax as indicated above. By signing this form, Physician is in agreement to educationally based therapy service as identified in the Individual Education Plan. Please be advised that this form will be valid for one year from the date signed. Medical Diagnosis and/or Description of Disability: _______________________________________________________________________Current Medication: _________________________________________________________________________________________________Precautions or Contraindications: ______________________________________________________________________________________Additional Comments: ________________________________________________________________________________________________Physician’s Name (please print): ________________________________________________________________________________________Physician’s Signature: ______________________________________ NPI#: ______________________________ Date: _______________PLEASE RETURN THE COMPLETED FORM TO THE OT/PT THERAPY OFFICE AT ADDRESS/FAX STATED ABOVE. Thank You!_____ Yes, the Physician would like a copy of the Occupational/Physical Therapy Portion of the IEP. _____ No, records not requested at this time. ................
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