Standard Appeal Form - Umass Dartmouth

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MEDICAL RELEASE FORM
Name (print): _____________________________
Stud ID: ____________
Campus Phone: _________________________
Current E-mail: _________________
___________________
Cell/Home Phone Number: ________________
Current Housing Assigned Building: _______________
Room ___________
Class Year: _____________________________
Home Street Address _____________________________________ Home City/State/Zip _____________________________________
STUDENT INSTRUCTIONS
1.
If you do not have a medical diagnosis with a work-up for your medical condition, please make an appointment with a
health care provider or contact the campus Health Office at 508 999 8982 to request an examination.
2.
If you do have a medical diagnosis with a work-up for your medical condition, please have the medical provider that
made the diagnosis complete the Health Care Provider section below.
HEALTH CARE PROVIDER
DIAGNOSIS:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
MEDICAL TESTING DONE TO CONFIRM DIAGNOSIS:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
TREATMENT PLAN:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Please explain why a release from the UMass Dartmouth Housing/Dining contract is necessary. Specifically indicate how the
patient’s medical circumstance has changed since the original signing of patient’s Housing/Dining contract.
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Provider Name (print): ________________________________
Provider Signature: ______________________________
Provider Address:
________________________________________________________________________________
Provider Telephone #: ________________________________
Date: _________________________________________
Mail/E-mail (scanned pdf)/Fax completed form to:
UMass Dartmouth
Director of Housing and Residential Life
285 Old Westport Road
North Dartmouth, MA. 02747
j2depina@umassd.edu and housing@umassd.edu
Fax #: 508 999 8949

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