Tuition Refund Plan - Notice of Claim

ATTENDING PHYSICIAN'S STATEMENT
This part to be completed by physician
 
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
 
Section A - Part I
I HEREBY CERTIFY THAT , a student at
                                                                      (NAME)                                                                        (SCHOOL/COLLEGE)
has been a patient under my care and has withdrawn from school due to the following medical condition(s):

                                                                                                             (DIAGNOSIS)
ICD Code #   or DSM Code #
The student has been unable to attend class from Select Date through Select Date
Date first consulted for this condition Select Date Date last consulted for this condition Select Date
Number of professional visits for this condition:      Home      Office      Hospital 
 
Completion of Part I is required for ALL absence/withdrawal claims.
Completion of Part II is required for all claims exceeding 30 days.
Your answers to the questions below should clearly establish the medical necessity for separation.
Section A - Part II
1. Is student still under your care for the above condition? (YES/NO)
2. If referred to another physician, please give name and address:
If student referred to you by another physician, please give name and address:
3. In your opinion, did this condition have its inception prior to August 1st last? (YES/NO) If "yes", please complete (a) & (b):
    (a) Did the student receive treatment for this condition between February 1 - August 1 last? (YES/NO)
    (b) Please provide dates of any treatment prior to August 1st last:
4. Has this student been withdrawn on your recommendation from classes for the rest of the current academic year? (YES/NO)
Please give reason for recommending or not recommending withdrawal:
5. When do you anticipate student will be able to resume classes at the above-mentioned School/College?  
6. Is student now attending or planning to enroll in another school/college (or become gainfully employed) during period of withdrawal from above-mentioned School/College? (YES/NO)   If "yes", is this with your permission? (YES/NO)
Give approximate date Select Date    
(PLEASE EXPLAIN)
7. Has the absence/withdrawal of this student resulted from the use of drugs or narcotics not authorized by a physician?  
    (YES/NO)
Signature of Physician M.D. Date Select Date
Please print name: Physician License #
Please print address: Telephone #
G41604 (03 09)