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Get Sample Request Letter For Medical Equipment

The College does not provide extension cords. June 2015 Saint Anselm College Name Campus Box Cell Phone Number YOG Email Address This is my first time applying for Medical Equipment. I have previously asked for Medical Equipment. Physician In order to determine the need of the individual student it is important that the medical documentation support the request and is complete. Policy A Medical Equipment Request Form with appropriate documentation must be submitted to Health Services. All requests will be reviewed on a case-by-case basis and documentation of a need for medical equipment esp* air conditioning does not guarantee that your application will be approved* Requirements and Process A completed Medical Equipment Request Form indicating a specific need and documentation from the physician providing care is required* The student s physician must provide documentation to the Director of Health Services. Approvals are determined on a case by case basis by the Director of Health Services and are dependent upon the documentation received relative to the severity of illness and the availability of rooms that have the capability of supporting the requested equipment. The documentation must include the diagnosis treatment plan and any additional information that would support the need for specific equipment. For example physician notes on a prescription such as Please provide an air conditioner for my patient due to allergies will not be accepted as documenting the need* Priority will be given to those students who have provided documented evidence of exacerbation of chronic respiratory diseases including asthma chronic medical conditions and those receiving allergy injections on a regular basis. Documentation needs to be up dated each year to maintain eligibility. All requests from upperclassmen must be received by February 27th for the following academic year requests from incoming first year students should be sent to Health Services by June 5th. The College uses ADA standards to determine pre-lottery housing* Need for medical equipment may not be a reason to be housed prior to the Lottery Process. Those students approved for medical equipment must obtain a sticker from Health Services. This sticker is to be affixed to the medical equipment in a spot that is easily visible. Sticker colors change annually and the student s sticker must be up to date. Air Conditioning Window Unit Requirements No higher than 14 No more than 120 volts No more than 7000 BTUs Must be Energy Star rated Need extension cord that is 12-3 wire with a ground for A/C units. The College does not provide extension cords. June 2015 Saint Anselm College Name Campus Box Cell Phone Number YOG Email Address This is my first time applying for Medical Equipment. I have previously asked for Medical Equipment. Physician In order to determine the need of the individual student it is important that the medical documentation support the request and is complete. Please indicate the specific accommodations you are requesting and reason for the request Describe the medical measures including medication and dosages being employed to treat this issue In order to process this request please attach clinical data documenting the medical problem* Physician s Signature Date Physician s Name Printed Physician s Address Please return form to Maura Marshall Director of Health Services Fax to 603 641-7318 100 Saint Anselm Drive 1722 Manchester NH 03102 OFFICE USE ONLY Recommended Accommodation Needed.

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