The following is a list of all the elements that are required for medical documentation to be considered sufficient to support a medical withdrawal request.
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Provider Credentials:
- Documentation must be written and signed by a licensed medical or mental health provider and must include the provider’s medical license number.
A Medical or Mental Health provider is defined as:
- Medical Doctor, MD
- Doctor of Osteopathy, DO
- Physician Assistant, PA
- Nurse Practitioner, NP
- Licensed Psychologist, Ph.D. Psy.D.
- Licensed Professional Clinical Counselor, LPCC
- Licensed Marriage and Family Therapist, LMFT
- Licensed Clinical Social Worker, LCSW
- Documentation from healthcare providers not explicitly listed above—such as Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Medical Assistants, chiropractors, or acupuncturists, etc., will not be accepted as valid documentation.
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Facility Information:
- The document must be written on the official letterhead or include a facility stamp with the phone number and address of the medical or mental health facility.
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Patient Identifers:
- The documentation must contain the patient’s name and date of birth or Campus Wide ID#.
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Clear identification of the medical condition/diagnosis:
- The documentation must specify the condition/diagnosis that is impacting the student’s ability to perform and succeed academically.
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The relevant timeframe of the condition:
- The documentation should identify the time period during which the condition has affected the student including any hospitalizations if applicable. These dates must coincide with the petition.
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A statement regarding how the condition affects academic performance:
- The letter must describe how the condition impairs the student’s ability to function successfully in their courses and why or how the condition prevents the student from completing your coursework.
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A recommendation regarding withdrawal:
- The letter must include a statement from the provider supporting or recommending the withdrawal from the semester and course(s) in question. Please note, when a partial withdrawal is requested, the documentation must specify which courses the provider recommends for withdrawal.
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Validation:
- The letter must be signed, dated by the treating medical/mental health care provider and include their license number; electronic signatures are accepted. If applicable, the signature and license number of the supervising professional is also required. An office stamp is required when submitting the provided form.
Note: The following items are not sufficient medical documentation for a medical withdrawal petition:
- Medical or clinical chart notes
- Lab results
- X-rays
- Hospital records
- Discharge papers
- Visit Summaries
- Attendance Verification
- DSS Approval Letter
- Medical bills
- Police reports
- Prescriptions/medication lists
- Medically related images or photographs
- Personal statements
