MEDICAL VERIFICATION FORM
Date:______________________
Student’s Name:________________________________________ Date of Birth:_________________
Dear Dr.
,
In order to comply with mandatory special education eligibility determination legislation, we need a
verification of the below-named student’s disability. Please complete and return the following
statement:
____________________________________________ has ___________________________________
Student’s Name
Disability
which is a (see definitions on cover letter):
Check
one
1.
2.
3.
4.
5.
6.
Physical Impairment R340.1709
Other Health Impairment R340.1709(a)
Traumatic Brain Injury R340.1716
Severe Multiple Impairment R340.1714
Visual Impairment R340.1708
Hearing Impairment R340.1707
____________________________________________
___________________________________
Doctor’s Signature and Title
Thank you for your time in helping us better serve this student.
Sincerely,
Date