<p> REQUEST FOR DIETARY ACCOMMODATIONS HEALTH CARE PROVIDER FORM </p><p>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.</p><p>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.</p><p>Student Signature: ______Date:______</p><p>Practitioner Name/Title: ______Date: ______</p><p>Address: ______</p><p>Telephone Number: ______License or Certification Number:______</p><p>Qualification to make diagnosis: ______</p><p>Date of most recent appointment with this student:______</p><p>1. Student’s specific diagnosis/diagnoses. Please include expected duration:</p><p>______</p><p>______</p><p>______</p><p>2. Severity of Student’s Condition (Mild, Moderate, Severe, etc.): </p><p>______</p><p>______</p><p>3. Please list all current medications: </p><p>______</p><p>______</p><p>______</p><p>______</p><p>Revised 5/18/17</p><p>5. Please explain how the diagnosis specifically affects the student’s ability to participate in the meal plan without dietary accommodations: ______</p><p>______</p><p>______</p><p>6. Please suggest reasonable dietary accommodations. Each accommodation must be supported by the diagnosis. </p><p>______</p><p>______</p><p>______</p><p>7. Please discuss the impact on your patient’s disability if the dietary accommodation can’t be provided. </p><p>______</p><p>______</p><p>______</p><p>Signature of Health Care Provider______Date: ______*The provider cannot be a family member of the student.</p><p>Please Return This Completed Form To:</p><p>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]</p><p>Revised 5/18/17</p>