COLLEGE MEDICAL WITHDRAWAL CERTIFICATE
STUDENT MEDICAL AUTHORIZATION
To be completed by the Student, Parent or Guardian
STEP I
Name of Insured Student
 
Social Security #:
I HEREBY AUTHORIZE the physician to complete the Attending Physician's Statement and to release this and other information to A.W.G. Dewar, Inc. for their use in documentation of claim for recovery of college fees from the insurance contract in effect at this time.  I authorize the College/University to release the information requested below to A.W.G. Dewar, Inc. for the same purpose.
Date Select Date
 
   Signature
(student if legal age, or parent or legal guardian)                         

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.
STEPS I and II should be completed and mailed to A.W.G. Dewar, Inc., 4 Batterymarch Park, Quincy, MA 02169-7468 as soon as possible; in any event, not later than 30 days after date of withdrawal.
STEP II ATTENDING PHYSICIAN'S STATEMENT
This part to be completed by physician.
 
 

I HEREBY CERTIFY THAT , a student at
                                                                           (Student's Name)                                                                              (College Name)

has been a patient under my care and withdrawn from college due to the following medical condition(s):

                                                                                                                        (diagnosis)
ICD Code #   or DSM Code #
Continuing treatment from Select Date (date) through Select Date (date)
First consulted Select Date (date)        Last consulted Select Date (date)
Number of professional visits for this disability:     Home       Office      Hospital
Your answers to the questions below should clearly establish the medical necessity for separation from College. 
1. Is student still under your care for the above disability?    (Yes/No)
2. If referred to another physician, please give name and address:  
 
  If student referred to you by another physician, please give the name and address: 
 
3. Has this student been withdrawn on your recommendation from classes for the rest of the current semester? (Yes/No)
    academic year?   (Yes/No).  Please give reason for recommending or not recommending withdrawal:
  
4. When do you anticipate student will be able to resume classes at the above-mentioned College? 
5. Has the withdrawal of this student resulted from the use of drugs or narcotics not authorized by a physician? (Yes/No)
6. If disability was due to a psychological illness, was student confined to a hospital?  (Yes/No)
    If Yes, provide dates of confinement and name and address of hospital. Confined from Select Date through Select Date
(date)                                          (date)
    Hospital Name & Address
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Signature of Physician , M.D. Date Select Date
Please print name Physician License #
Please print address  Telephone # 
G42021-B 03/09 (STD)