Forms

The following files are in PDF format. A free PDF reader, Adobe Acrobat, is available for download.

• Health Report

• Application for the Learning Disabilities Program

• Release of Medical Records form

• Meningitis Waiver

Medical Leave of Absence
A Medical Leave of Absence (MLOA) is an option to consider when a student is diagnosed with a major medical illness, injury, or psychiatric illness, after the start of the term that significantly interferes with his or her ability to attend classes and complete requirements.

Medical leave requests must be initiated through University Health and Counseling Services by sending a completed request form and documentation from a clinician supporting the medical leave.

Return to classes following a MLOA requires a completed request for re-entry form and clinical documentation supporting the re-entry to classes be faxed, sent, or delivered to UHCS on or around one month prior to planned re-entry.  Clinical documentation supporting the re-entry must include an appointment date with a clinician outside of UHCS after re-entry and be submitted with the request.  Below are the request forms (PDF):

• Request for Medical Leave of Absence

• Request for Re-entry from Medical Leave of Absence

The Insurance and Referral Coordinators will be assistance in the MLOA process and in finding community referrals upon return from MLOA if needed. They can be reached at 617-373-2772 option #5.