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Medical Professionals

Physicians/PsychiatristsGeneral education students in grades K-12 may be eligible for service from Home & Hospital if: they have a medically verified, non-contagious physical condition(s) or a temporary physical disability that cannot be accommodated at their home school. 

A Physician/Psychiatrist referral must be completed and signed by a California licensed physician or psychiatrist and include a diagnosis as well as an estimated return date.  The return date may not exceed 9 weeks.

Please complete,  print, and sign the form and return to the student’s home school. 

Students referred to H&H must have a medical or psychological condition, verified by a licensed doctor.


  • States the need for Home/Hospital Instruction.

  • Student must be out of school for five days or more.  

  • The referral may not exceed 9 weeks.

Eligibility will be reviewed every 9 weeks and requires a new medical or psychiatric referral to extend services.



*Note for Kaiser Patients: Parents may also send the blank form to the ROMI Diablo Area Office at Completed forms are returned to you, rather than to a third party, so you can review the information and make a copy for your records first. The completed form should then be sent with the completed application forms to the student's home school to complete the registration process at Home & Hospital.