Rutherford County Schools

RUTHERFORD COUNTY SCHOOLS

HEALTH CARE PROVIDER DOCUMENTATION FOR HOMEBOUND SERVICES

PARENTS TO COMPLETE THIS PORTION and fax to 615-904-3797

Student Name: ______DOB: ______Age: ______

School: ______Grade: ______Receives Special Ed Services: Y / N Has a 504: Y / N

Parent(s)/Guardians: ______

Address: ______City, State, Zip: ______

Home Phone: ______Cell Phone: ______Work Phone: ______

Parent e-mail address: ______

Dear Health Care Provider: A student approved for Homebound Services receives instruction from a teacher in the home 2 times per week for 1 ½ hours each visit, for a total of 3 hours per week. This is in contrast to the approximately 35 hours of instruction in a regular school week. In order to determine whether it would be in this student’s best interest to receive Homebound Services or whether other educational modifications would be more appropriate, Rutherford County Schools requires the following information: (1) a current diagnosis; (2) a treatment plan; and (3) supporting documentation from office visits and/or hospitalization and a subsequent discharge summary.

HEALTH CARE PROVIDER TO COMPLETE THIS PORTION - FAX TO 615-904-3797

Health Care Provider Name: ______Phone: ______Fax: ______

Address: ______City, State, Zip: ______

Is the student currently hospitalized? Yes / No; if yes, expected date of discharge: ______

If not currently, has the student been hospitalized recently? Yes / No; if yes, date of discharge: ______

When was this student last examined? ______

What is this student’s diagnosis? ______

Please rate the student’s prognosis: Good ___ Fair ___ Poor ___ Other ______

Is this student’s condition communicable? Yes / No; If yes, please explain: ______

Is this student currently immunocompromised? Yes / No; If yes, why? ______

List medications student is currently taking: ______

Describe student’s treatment plan/therapy: ______

Does the student require any activity restrictions? Yes / No; if yes, please describe: ______

Expected length of recovery: ______days; ______weeks; ______months; other: ______

On what date will the student be well enough to have a teacher come to the house and do work? ______

On what date is student expected to return to school full time? ______

The Homebound Committee consists of a School Psychologist, a School Counselor, and a Registered Nurse. Please describe the student’s condition as completely as possible to give the committee a clear picture of his/her condition that makes attending school impossible or unsafe. ______

Health Care Provider Signature: ______Date: ______

11/2013 Fax to 615-904-3797