College Medical Withdrawal Certificate Form

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COLLEGE MEDICAL WITHDRAWAL CERTIFICATE
STEP I
STUDENT MEDICAL AUTHORIZATION
To be completed by Student, Parent or Guardian
Name of Insured Student
Social Security #
________________________________________
I HEREBY AUTHORIZE the physician to complete the Attending Physician’s Statement and to release this and other information to
A.W.G. Dewar, Inc. for their use in documentation of claim for recovery of college fees from the insurance contract in effect at this time.
I authorize the College/University to release the information requested below to A.W.G. Dewar, Inc. for the same purpose.
Date
Signature
_____________________
(student if legal age, or parent or legal guardian)
PLEASE SEE THE REVERSE SIDE OF THIS FORM FOR IMPORTANT FRAUD
INFORMATION REGARDING YOUR CLAIM.
STEPS I and II should be completed and mailed to A.W.G. Dewar, Inc., 4 Batterymarch Park, Quincy, MA
02169-7468 as soon as possible; in any event, not later than 30 days after date of withdrawal.
STEP II
ATTENDING PHYSICIAN’S STATEMENT
This part to be completed by physician.
I HEREBY CERTIFY that ___________________________________, a student at
,
(Student’s Name)
(College Name)
has been a patient under my care and withdrawn from college due to the following medical condition(s):
(diagnosis)
ICD Code # ____________________________________ or DSM Code #
Continuing treatment from __________________________________ through
(date)
(date)
First consulted _____________________________________
Last consulted
(date)
(date)
Number of professional visits for this disability:
Home ________________ Office ________________ Hospital
Your answers to the questions below should clearly establish the medical necessity for separation from College.
Is student still under your care for the above disability?
1.
___________________________________________________ (Yes/No)
If referred to another physician, please give the name and address
2.
:
If referred to you by another physician, please give the name and address
:
Do you medically certify that the sickness or injury diagnosed prevents the student from completing the rest of the current
3.
semester ?
)
academic year
Please give reason for your answer
_____ (Yes/No
? _____ (Yes/No)
:
When do you anticipate student will be able to resume classes at the above-mentioned College?
4.
Has the withdrawal of this student resulted from the use of drugs or narcotics not authorized by a physician?
5.
________ (Yes/No)
Was the student confined to a hospital for this sickness or injury
If Yes, provide dates of confinement and
6.
? ______ (Yes/No)
name and address of hospital.
Confined from
through
_______________
_______________
(date)
(date)
Hospital Name & Address
----------------------------------------------------------------------------------------------------------------------------------------------------------------------
Signature of Physician ___________________________________________________________, M.D. Date
Please print name ______________________________________________________________ Physician License #
Please print address ___________________________________________________________________ Telephone#
G42021-B 04 10 (STD)

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