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Get Health Care Provider Form Fitchburg

HEALTH CARE PROVIDER VERIFICATION FORM Return form to Jeff McMaster Director of Student Accounts/ Fitchburg State University Attn Tuition Appeals / 160 Pearl Street Fitchburg MA 01420 / Fax 978-665-3559 CONSENT TO RELEASE MEDICAL INFORMATION I give my permission for my Health Care Provider to release information to Fitchburg State University concerning my condition as it relates to my request for a waiver of tuition and fees. Signature of Student Date Signature of Parent/Guardian Date if student under the age of 18 Completion of this form does not guarantee a refund. The Tuition Appeals Committee reviews all materials submitted and makes a recommendation for approval or denial of appeals. The decision of the Tuition Appeals Committee is final. INSTRUCTIONS TO THE HEALTH CARE PROVIDER In order to consider a petition for a waiver of tuition or fees due to medical reasons Fitchburg State University requires documentation from a licensed Health Care Provider verifying a current condition that prevents the student from attending the university during this semester. Please provide the following information along with a signed piece of letterhead after the student/ patient has completed the release consent at the top of this form. Name of Student Patient Last First Middle Patient s Student ID Describe Student/Patient s condition and how it prevents the student from attending the university. Attach additional sheets as necessary Date of first visit When did you last examine the student I certify that in my professional opinion the above named student is currently unable to attend Fitchburg State University during the of due to the conditions described above. semester year Health Care Provider s Signature Date Health Care Provider s Phone Number Student Accounts 20746 health care provider verification.indd 7/12. The decision of the Tuition Appeals Committee is final. INSTRUCTIONS TO THE HEALTH CARE PROVIDER In order to consider a petition for a waiver of tuition or fees due to medical reasons Fitchburg State University requires documentation from a licensed Health Care Provider verifying a current condition that prevents the student from attending the university during this semester. Please provide the following information along with a signed piece of letterhead after the student/ patient has completed the release consent at the top of this form. Name of Student Patient Last First Middle Patient s Student ID Describe Student/Patient s condition and how it prevents the student from attending the university. Signature of Student Date Signature of Parent/Guardian Date if student under the age of 18 Completion of this form does not guarantee a refund. The Tuition Appeals Committee reviews all materials submitted and makes a recommendation for approval or denial of appeals. The decision of the Tuition Appeals Committee is final* INSTRUCTIONS TO THE HEALTH CARE PROVIDER In order to consider a petition for a waiver of tuition or fees due to medical reasons Fitchburg State University requires documentation from a licensed Health Care Provider verifying a current condition that prevents the student from attending the university during this semester.

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