|College Medical Withdrawal Certificate - Student Medical Authorization|
|College Medical Withdrawal Certificate - Student Information Release|
- Please complete and sign Step I of each claim form.
- Please forward the Student Medical Authorization form to the attending physician that was seen at the time of the withdrawal. Once the doctor has completed Step II, please forward the form to our office.
- Please forward the Student Information Release form to the University for the completion of Step II (A & B). The University will then forward the form to our office.
Upon receipt of both forms, the claim will be reviewed.
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