• Per USDA memo SP 32-2015, a state authorized medical authority is a state licensed health care provider who is authorized to write medical prescriptions under state law. In Wisconsin this is a physician, dentist, optometrist, podiatrist, physician assistant, or nurse practitioner. In addition, the Final Rule-Child Nutrition Programs: Meal Patterns Consistent With the 2020-2025 DGAs, section 14 permits registered dietitians to request meal modifications on behalf of a child with a dietary disability.

• If the request for a meal modification is not for a disability or has not been signed by one of these practitioners, the school is not required to provide a meal accommodation.

An authorized medical statement must:

• Include an explanation of how the child’s physical or mental impairment restricts the child's diet

• Identify the food(s) to be avoided

• Identify the food(s) to be substituted

• Be signed by a state authorized medical authority or a registered dietitian.

To approve your child for food allergy accommodations, please download the form below and return with the medical practitioner's signature. Pease send the completed form to your child's Food Service Director:

Brenda Utesch at BFHS, P.O. Box 99, Walworth, WI 53184, Email: Brenda Utesch

Within 1 week of receiving the completed form, a parent/guardian will be contacted and informed if meal & beverage substitutions will be provided or if more information is needed. It is the responsibility of the household to provide appropriate foods/beverages until informed otherwise. 

 Diet Modification Form: English   Español