Medically Necessary Air Conditioner Request



Provider Request for a Medically Necessary Air ConditionerGettysburg CollegeForm InstructionsWhile some medical circumstances do not rise to the level of a disability, Gettysburg College recognizes that reasonable accommodations may be necessary to assist students in the management of their healthcare needs. A student requiring an air conditioner must submit this request form that has been completed and signed by their licensed healthcare provider (MD, DO, CRNP, PAc, Medical Specialist).I. StudentTo be completed by the student.Last name: FORMTEXT ?????First name: FORMTEXT ?????Middle initial: FORMTEXT ?????Date of birth: FORMTEXT ?????Student ID number: FORMTEXT ?????Residence hall: FORMTEXT ?????Room number: FORMTEXT ?????II. Licensed Healthcare ProviderTo be completed by the licensed healthcare provider.Full name: FORMTEXT ?????Area of specialty: FORMTEXT ?????License number and state: FORMTEXT ?????Address: FORMTEXT ?????Office phone number: FORMTEXT ?????Fax number: FORMTEXT ?????III. Medical Condition InformationTo be completed by the licensed healthcare provider.1. Type of conditionType of medical condition or allergy requiring an air conditioner: FORMTEXT ?????2. Condition durationHow long has this student been under your care for this medical condition: FORMTEXT ?????3. Last evaluationLast time you evaluated the student for the above medical condition: FORMTEXT ?????4. Symptoms FORMTEXT ?????Are symptoms: Continuous FORMCHECKBOX Intermittent FORMCHECKBOX Seasonal FORMCHECKBOX Severity:Mild FORMCHECKBOX Moderate FORMCHECKBOX Significant FORMCHECKBOX 5. TreatmentPrescribed medication or treatment taken to manage symptoms: FORMTEXT ?????6. Anticipated benefitPlease specify how the air conditioner will assist in the treatment of the student’s medical condition: FORMTEXT ?????7. Significance for allergiesTo manage the student’s allergies, is the use of an air conditioner: Desirable:Yes FORMCHECKBOX No FORMCHECKBOX Essential:Yes FORMCHECKBOX No FORMCHECKBOX 8. Significance for other conditionsTo manage student’s other medical conditions, is the use of an air conditioner:Desirable:Yes FORMCHECKBOX No FORMCHECKBOX Essential:Yes FORMCHECKBOX No FORMCHECKBOX IV. Signature and DateProvider signature: FORMTEXT ?????Date: FORMTEXT ?????V. Form SubmissionSubmit completed form to:Center for Student SuccessGettysburg College300 North Washington St, Campus Box 430College Union Building 250Gettysburg, PA 17325Phone: (717) 337-6579Fax: (717) 337-6245Office Use OnlyHealthcare Professional Office stamp:rev. 06062022 ................
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