Medical Accommodations Medical Provider Request Form

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Offices and Administration

APPLY! REQUEST

Medical Accommodations Medical Provider Request Form

Please complete the Medical Accommodations Medical Provider Request Form and submit electronically.

- indicates required field

Student First Name

Student Middle Name

Student Last Name

What is the relevant medical diagnosis?

Date of diagnosis:

Last office visit:

The condition is:

If temporary, what is the anticipated duration?

Prescribed medication(s): Indicate Dosage

Please describe the type, severity, and frequency of symptoms currently experienced by the student and how the disability interferes with one or major life activities:

Please identify the recommended housing accommodation

If other, please specify:

Please explain how the recommended housing accommodation relates to and impacts the condition: (Disability or Chronic Medical Condition)

Is the desired housing accommodation beneficial or required?

How will the student manage these symptoms in other campus settings (e.g. classroom, dining halls, etc.)

Please indicate how this student may be at risk during an emergency evacuation (e.g. fire, tornado)

Medical Provider Full Name

Medical Provider Phone Number

Medical Provider Address

Medical Provider License Number

My signature below indicates that I am the treating professional and that all contents are accurate. I verify that I am not a relative or friend of the student.

Name

Date

Please make sure all required fields have been filled out correctly.

Your Medical Accommodations Medical Provider Request Form has been submitted and will be reviewed within 7-10 business days. The requesting student will be contacted via UNA email with additional information. Please contact Housing & Residence Life with any questions.

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Medical Accommodations Medical Provider Request Form

Verification

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Medical Accommodations Medical Provider Request Form

Verification

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