Student medical leave form 2026

1. Click ‘Get Form’ to open the student medical leave form in the editor.
2. In Section 1, complete all fields including Group No., Subscriber Identification No., Subscriber Name, Dependent Student Name, and Dependent Student Date of Birth. Ensure accuracy as this information is crucial for processing.
3. Sign and date the certification statement at the bottom of Section 1 to confirm that the provided information is correct.
4. Move to Section 2, which must be filled out by the attending physician. They need to indicate whether the student is suffering from a serious illness or injury by checking 'Yes' or 'No'.
5. If applicable, provide an explanation of the medical condition and attach any additional information if necessary.
6. The physician must also confirm if the leave of absence is medically necessary and specify the effective date and end date for the medical leave.
7. Finally, ensure that the attending physician signs and dates this section along with providing their NPI Number.

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