Medically Prescribed Treatment (Non-Medication) Form — Provider Treatment Order Form | Office of School Health | School Year 2025–2026 Instructions

Check this box when there are any extra or supplemental instructions, treatments, or details that are not covered elsewhere on the form and additional information is provided in the space following this label.

Enter any extra instructions, details, or special treatment information related to the order (e.g., procedures, timing, precautions, or clarifications) that school staff should follow.

Enter the full name of the alternate emergency contact (first and last name) who may be reached if the primary guardian is unavailable.

Provide the alternate contact's relationship to the student (for example: parent, grandparent, aunt/uncle, neighbor, etc.).

Enter the best phone number to reach the alternate emergency contact, including area code and any necessary punctuation or extension.

Enter any specific medical conditions, signs, symptoms, or situations in which the prescribed treatment must not be given (i.e., list what to watch for and state “Do not treat if…” followed by the relevant contraindications).

Enter the student's primary diagnosis or brief description of the medical condition related to this treatment.

Check this box if the diagnosis is self-limited (expected to resolve on its own).

Check this box when you are entering the first ICD-10 code and related condition for the diagnosis and complete the adjacent code/condition line. Fill only if 'Diagnosis' is filled.

Enter the first ICD-10 code related to the diagnosis (include letters and any decimal point as required). Fill only if 'Diagnosis' is filled.

Enter a second ICD-10 code related to the diagnosis, if applicable (include letters and any decimal point as required). Fill only if 'Diagnosis' is filled.

Check this box when you are entering the second ICD-10 code and related condition for the diagnosis and complete the adjacent code/condition line. Fill only if 'Diagnosis' is filled.

Enter an additional ICD-10 code related to the diagnosis, if applicable (include letters and any decimal point as required). Fill only if 'Diagnosis' is filled.

Enter another ICD-10 code related to the diagnosis, if applicable (include letters and any decimal point as required). Fill only if 'Diagnosis' is filled.

Check this box when you are entering the third ICD-10 code and related condition for the diagnosis and complete the adjacent code/condition line. Fill only if 'Diagnosis' is filled.

Enter an additional ICD-10 code related to the diagnosis, if applicable (include letters and any decimal point as required). Fill only if 'Diagnosis' is filled.

Check this box if the diagnosis is not self-limited (not expected to resolve on its own).

Enter a final ICD-10 code related to the diagnosis, if applicable (include letters and any decimal point as required). Fill only if 'Diagnosis' is filled.

Enter detailed, step‑by‑step emergency treatment instructions for clinical personnel and school staff to follow in case of an adverse reaction, dislodgement, blockage, or other emergency related to the student’s tracheostomy, feeding tube, or prescribed non‑medication treatment.

Check this box when the student requires a prescribed feeding/formula administered at school as part of their treatment order.

Enter the prescribed formula name or type/brand to be used for the student’s feedings. Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

Provide the concentration or strength of the formula/feeding solution as ordered (for example strength, kcal/oz, or dilution). Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

Specify the route of administration for the feeding (for example G‑tube, NG tube, J‑tube, or oral). Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

Enter the numeric amount of formula to be given per feeding as ordered. Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

Indicate the administration rate for the formula, including any units or descriptors (for example bolus or continuous rate). Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

State the duration of each feeding or the total time the feeding should run (for example minutes, hours, or 'continuous'). Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

List how often the feedings should occur and/or the specific clock time(s) for administration (for example 'every 4 hours' or specific times). Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

Check this box when a flush is required as part of the feeding/tube procedure and you will specify the flush volume (mL) on the form. Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

Enter the volume in milliliters to be used for the flush (numeric value, may include decimals). Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

Enter when the flush should be given (for example: 'Before feeding', 'After feeding', or other specific timing). Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

Check this box when the flush or other action must be performed immediately before each feeding. Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

Check this box when the flush or other action must be performed immediately after each feeding. Fill only if 'Feeding: Formula (treatment required in school)' is 'Yes'.

Check this box if the student requires a nurse to administer the prescribed treatment (student cannot self-administer).

Check this box if the health care practitioner completing the form is a Medical Doctor (MD).

Check this box if the health care practitioner completing the form is a Doctor of Osteopathy (DO).

Check this box if the health care practitioner completing the form is a Nurse Practitioner (NP).

Check this box if the health care practitioner completing the form is a Physician Assistant (PA).

Check this box if the student will self-treat but requires adult supervision while doing so.

Check this box if the student is permitted to self-carry and/or self-administer the treatment independently (student must initial where indicated).

Check this box if the student was referred to the School 504 Coordinator.

Check this box if the student was NOT referred to the School 504 Coordinator.

Enter the health care practitioner's last name (printed) as it appears on their professional credentials.

Enter the health care practitioner's first name (printed).

Enter the date the practitioner signed or completed this form.

Enter the practitioner's New York State professional license number.

Enter the practitioner's National Provider Identifier (NPI) number.

Provide the practitioner's office or practice address, including street, city, state, and ZIP code.

Enter the practitioner's email address for contact about the prescribed treatment.

Provide the practitioner's primary office telephone number for contact about the treatment order.

Provide the practitioner's office fax number if available.

Provide the practitioner's mobile phone number for urgent or after-hours contact.

Check this box when the student requires blood pressure monitoring as part of the ordered treatment.

Check this box when chest clapping or percussion therapy is ordered to help clear the student's airways.

Check this box when clean intermittent catheterization is ordered and record the catheter size in French (Fr) units.

Enter the catheter size in French units (Fr) used for clean intermittent catheterization (e.g., 8, 10, 12). Fill only if 'Clean Intermittent Catheterization (Cath Size ___ Fr.)' is 'Yes'.

Check this box when care, access, or management of a central venous/PICC line is required for the student.

Check this box when scheduled or as‑needed dressing changes are required for a wound or device.

Check this box when enteral feeding via a tube/catheter is ordered and specify the catheter size in French (Fr) units.

Enter the feeding tube or catheter size in French units (Fr) for the feeding method specified (e.g., 8, 12). Fill only if 'Feeding (Cath Size ___ Fr.)' is 'Yes'.

Check this box when the student uses a nasogastric (NG) feeding tube.

Check this box when the student uses a gastrostomy (G‑tube) for enteral feeding.

Check this box when the student uses a jejunostomy (J‑tube) for enteral feeding.

Check this box when feedings are to be given as bolus (intermittent) feeds rather than continuous delivery. Fill only if 'Nasogastric', 'G‑Tube', 'J‑Tube' is 'Yes' (any).

Check this box when feedings are to be delivered using a feeding pump. Fill only if 'Nasogastric', 'G‑Tube', 'J‑Tube' is 'Yes' (any).

Check this box when feedings are to be delivered by gravity (free‑flow) method. Fill only if 'Nasogastric', 'G‑Tube', 'J‑Tube' is 'Yes' (any).

Check this box when a special or non‑standard feeding method is required and provide the specific details in the indicated space. Fill only if 'Nasogastric', 'G‑Tube', 'J‑Tube' is 'Yes' (any).

Check this box when the student is authorized to have a feeding tube replaced if it becomes dislodged (see referenced specification field #5 on the form). Fill only if 'Nasogastric', 'G‑Tube', 'J‑Tube' is 'Yes' (any).

Check this box when the student requires oral or pharyngeal suctioning as a prescribed procedure and catheter size should be documented on the form.

Enter the catheter size in French (Fr) to be used for oral or pharyngeal suctioning (e.g., 8, 10, 12). Fill only if 'Oral / Pharyngeal Suctioning' is 'Yes'.

Check this box when ostomy care (routine cleaning/maintenance) is ordered for the student.

Check this box when oxygen administration is prescribed for the student (including any pulse oximetry monitoring) and specify required details in the referenced specification field.

Check this box when postural drainage therapy is prescribed as part of the student's respiratory care.

Check this box when pulse oximetry monitoring is required for the student and include any specification details in the referenced field.

Check this box when routine tracheostomy care is ordered and provide the tracheostomy tube size on the form.

Enter the tracheostomy tube size to be used for trach care as specified by the provider. Fill only if 'Trach Care (specify trach size)' is 'Yes'.

Check this box when the provider authorizes tracheostomy tube replacement and include the required replacement details in the referenced specification field. Fill only if 'Trach Care (specify trach size)' is 'Yes'.

Check this box when suctioning of the tracheostomy is prescribed and indicate the catheter size (Fr) on the form.

Enter the catheter size in French (Fr) to be used for tracheostomy suctioning (e.g., 8, 10, 12). Fill only if 'Trach suctioning (specify catheter size)' is 'Yes'.

Check this box when an additional procedure not listed is being ordered and provide a clear description of that procedure on the provided line.

Provide a brief, specific description of any other procedure, equipment, or instruction not listed elsewhere on the form. Fill only if 'Other (specify)' is 'Yes'.

Enter clear, step-by-step instructions for non-medical school staff to follow in case of adverse reactions, dislodgement of a tracheostomy or feeding tube, or other emergencies related to the prescribed non-medical treatment.

Enter the student's OSIS identification number assigned by the school or district.

Enter the full name of the person who received the form on behalf of the school or OSH.

Enter the date the form was received by the school or OSH.

Enter the full name of the OSH staff member who reviewed the form.

Enter the date the form review was completed by OSH staff.

Check this box if the student has an active Section 504 accommodation plan.

Check this box if the student has an active Individualized Education Program (IEP).

Check this box if the student has another plan or status not listed here (provide details in the 'Other' field).

Check this box if services are being provided by a nurse or nurse practitioner.

Check this box if services are being provided by an OSH Public Health Advisor (applies to supervised students only).

Check this box if services are being provided by the School Based Health Center.

Enter the date the school was notified and the form was sent to the DOE liaison.

Check this box when the form was revised following contact between OSH and the prescribing health care practitioner.

Check this box when the practitioner is ordering an additional treatment not listed elsewhere on the form and will provide the treatment name, route, frequency/specific times, and the signs or symptoms to watch for.

Enter the name of the other non-medication treatment or procedure to be provided (for example: wound care, nebulization, catheter irrigation). Fill only if 'Other Treatment (Treatment name, Route, Frequency/specific time(s) of administration, Signs & symptoms)' is 'Yes'.

Enter the route or method by which the treatment is administered (for example: oral, topical, G-tube, nebulizer, IV). Fill only if 'Other Treatment (Treatment name, Route, Frequency/specific time(s) of administration, Signs & symptoms)' is 'Yes'.

Provide when and how often the treatment should be given, including exact times, intervals, or PRN instructions (for example: every 4 hours, at 0900 and 1500, PRN for coughing). Fill only if 'Other Treatment (Treatment name, Route, Frequency/specific time(s) of administration, Signs & symptoms)' is 'Yes'.

Describe the signs or symptoms that indicate the treatment is needed and include any additional instructions, precautions, or monitoring requirements. Fill only if 'Other Treatment (Treatment name, Route, Frequency/specific time(s) of administration, Signs & symptoms)' is 'Yes'.

Check this box when the student requires oxygen administration as a prescribed school treatment and you will fill in amount, route, frequency, and other details on the line.

Enter the prescribed oxygen flow rate in liters per minute to be administered. Fill only if 'Oxygen Administration (including pulse oximetry)' is 'Yes'.

Specify the delivery method for the oxygen (for example, nasal cannula, face mask, or tracheostomy). Fill only if 'Oxygen Administration (including pulse oximetry)' is 'Yes'.

Provide the exact schedule or frequency when oxygen should be given (for example, continuous, PRN with parameters, or specific times of day). Fill only if 'Oxygen Administration (including pulse oximetry)' is 'Yes'.

Check this box when oxygen is to be given PRN (as needed) rather than on a scheduled basis. Fill only if 'Oxygen Administration (including pulse oximetry)' is 'Yes'.

Check this box when oxygen should be administered based on the student's oxygen saturation falling below a specified percentage (enter the threshold and associated signs/symptoms). Fill only if 'Oxygen Administration (including pulse oximetry)' is 'Yes'.

If oxygen is to be given PRN, specify the oxygen saturation percentage at or below which oxygen should be administered. Fill only if 'Oxygen Administration (including pulse oximetry)' is 'Yes'.

List the clinical signs or symptoms that indicate oxygen should be administered or that require reassessment (for example, shortness of breath or increased respiratory rate). Fill only if 'Oxygen Administration (including pulse oximetry)' is 'Yes'.

Enter the parent or guardian's email address for school contact about the student's medically prescribed treatment.

Enter the parent or guardian's full home mailing address (street, city, state, and ZIP).

Enter a daytime telephone number (including area code) where the parent or guardian can be reached.

Enter the parent or guardian's home phone number (including area code), if different from the daytime number.

Enter the parent or guardian's mobile/cell phone number (including area code) for text or call contact.

Enter the full name of the parent or guardian who is completing and signing this form.

Enter the date on which the parent or guardian signed this form.

Describe any possible side effects or adverse reactions to the prescribed treatment, including expected signs/symptoms, typical timing/onset, severity, and any actions staff should take if they occur.

Check/initial this box when the practitioner attests that the student has demonstrated the ability to self-administer the prescribed treatment effectively during school, field trips, and school‑sponsored events.

Enter the practitioner's initials to attest that the student demonstrated the ability to self-administer the prescribed treatment effectively during school, field trips, and school‑sponsored events. Fill only if 'Independent Student' is 'Yes'.

Check this box if the student will require the prescribed non-medication treatment while being transported (e.g., on a bus or other school-arranged transport).

Check this box if the student will require the prescribed non-medication treatment during school-sponsored trips or field trips away from campus.

Check this box if the student will require the prescribed non-medication treatment while participating in afterschool programs or activities.

Enter the school's ATS/DBN code or the full school name as it appears in district records.

Enter the borough where the school is located (e.g., Bronx, Brooklyn, Manhattan, Queens, Staten Island).

Enter the school district identifier or number associated with the school.

Enter the student's legal or preferred last (family) name.

Enter the student's legal or preferred first (given) name.

Enter the student's middle initial (single letter) or leave blank if none.

Enter the student's date of birth.

Check this box if the student's sex is male; check only if this accurately reflects the student's recorded sex.

Enter the student's OSIS number (the unique student identification number assigned by the district).

Enter the student's current grade level (for example K, 1, 2, 9, 12).

Enter the student's class or homeroom identifier used by the school.

Enter the student's Department of Education district number or name.

Enter the full school information including DBN or AT SDBN code, official school name, address, and borough.

Check this box if the student's sex is female; check only if this accurately reflects the student's recorded sex.

Enter the student's family/last name exactly as it appears on school records.

Enter the student's given/first name exactly as it appears on school records.

Enter the student's middle initial (single letter) if applicable, or leave blank if none.

Enter the student's date of birth.

Enter the date when the prescribed treatment should begin (the initiation date).

Enter the date when the prescribed treatment should end or be discontinued (the termination date).