Tip for District-specific

You do NOT need a medical diagnosis to request a 504 evaluation — the school must evaluate

Tip for District-specific

Put your request in writing and keep a dated copy — verbal requests are harder to enforce

Tip for District-specific

Section 504 covers ANY disability that substantially limits a major life activity — the scope is broad

Maternal & PediatricmoderateDoctor signature required

Section 504 Plan (Medical)

District-specific · School districts

Accommodation plan for students with health conditions (diabetes, allergies, asthma, ADHD) that impact school participation. Includes a medical management plan and emergency action plan.

Form Details

Total fields: 40
Auto-fillable: 25 (63%)
Time without BeneFill: 45 minutes
Time with BeneFill: 12 minutes
Time saved: 33 minutes
Filled by: both
Frequency: annual

Fill this form with BeneFill

Auto-fill 63% of fields from your profile. Save 33 minutes. Download a real PDF.

25 of 40 fields63% auto-filled

Start Filling Upload Your Copy Instead

Where to Submit This Form

🏢

Submit request to school principal or 504 coordinator

Request a 504 evaluation in writing and keep a dated copy.

📬

Mail to the school district's 504 coordinator

Send via certified mail with return receipt to establish a formal record.

Filing Deadline

No federal deadline to request. Schools must evaluate within a reasonable time (typically 30-60 days depending on state/district policy).

Required Attachments

📎 Written request for 504 evaluation
📎 Medical documentation of the disability or condition from a healthcare provider
📎 Any relevant evaluations, test results, or specialist reports
📎 Documentation of how the condition limits a major life activity (e.g., learning, breathing, eating)

Processing Time

30-60 days for initial evaluation and plan development. The school must convene a 504 team meeting.

What Happens Next

The school's 504 team will review documentation, determine eligibility, and develop an accommodation plan. Parents must be part of the team. The plan is reviewed at least annually.

Tips for This Form

✓ You do NOT need a medical diagnosis to request a 504 evaluation — the school must evaluate
✓ Put your request in writing and keep a dated copy — verbal requests are harder to enforce
✓ Section 504 covers ANY disability that substantially limits a major life activity — the scope is broad
✓ If the school denies your request, you can file a complaint with the Office for Civil Rights (OCR)
✓ A 504 plan is different from an IEP — it provides accommodations but not specialized instruction

More Maternal & Pediatric Forms

WIC Application

State-specific · USDA Food and Nutrition Service (state-administered)

Application for WIC nutrition assistance providing education, breastfeeding support, and benefits for healthy foods. Requires proof of identity, address, income (or Medicaid/SNAP/TANF participation), and a health screening.

WIC Medical Documentation / Nutrition Risk Form

State-specific · State WIC agencies

Medical documentation of nutrition risk factors qualifying an individual for WIC, such as anemia, underweight, or high-risk pregnancy.

CHIP Application

State-specific / Healthcare.gov · State CHIP agencies

Application for Children's Health Insurance Program for families with income too high for Medicaid but too low for private coverage. Uses MAGI-based financial eligibility. Children must be uninsured.

School Entrance Health Form

State-specific (e.g., VA MCH213G) · State Departments of Health/Education

Required for school entry. Includes immunization records, health history, physical examination, and developmental screening. Must be completed no earlier than one year before school entry.

Immunization Record / Certificate of Immunization

State-specific · State Departments of Health

Official record of required childhood vaccinations for school enrollment. Exemption forms (medical, religious, philosophical) vary by state.

Medication Administration Authorization (School)

District-specific · School districts

Authorization for school nurse or designee to administer prescribed medication during school hours.

Not sure which forms you need?

Tell our assistant about your situation and we'll find the right forms for you.

Chat with Form Assistant

Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the School districts or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.