Health Care Provider Form

REQUEST FOR DIETARY ACCOMMODATIONS HEALTH CARE PROVIDER FORM

Dear ______, You are being asked to provide documentation for your patient/client, ______. Please fill out the two-sided form below and attach any appropriate supplemental documentation. Thank you in advance for your cooperation in this matter. Applications will be reviewed on a case by case basis by a committee of Emmanuel College professionals.

By signing below, I certify that the above statement is correct, and I authorize Emmanuel College to release or exchange information with my medical provider and other institution officials as necessary to assist in this accommodation process.

Student Signature: ______Date:______

Practitioner Name/Title: ______Date: ______

Address: ______

Telephone Number: ______License or Certification Number:______

Qualification to make diagnosis: ______

Date of most recent appointment with this student:______

1. Student’s specific diagnosis/diagnoses. Please include expected duration:

______

2. Severity of Student’s Condition (Mild, Moderate, Severe, etc.):

______

3. Please list all current medications:

______

Revised 5/18/17

5. Please explain how the diagnosis specifically affects the student’s ability to participate in the meal plan without dietary accommodations: ______

______

6. Please suggest reasonable dietary accommodations. Each accommodation must be supported by the diagnosis.

______

7. Please discuss the impact on your patient’s disability if the dietary accommodation can’t be provided.

______

Signature of Health Care Provider______Date: ______*The provider cannot be a family member of the student.

Please Return This Completed Form To:

Alyson Czelusniak Assistant Director of Disability Support Services Emmanuel College 400 The Fenway Boston, MA 02115 617-735-9923 Confidential Fax: 617-975 9322 [email protected]

Revised 5/18/17