Laurier verification of illness form 2025

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By signing this form, you confirm whether or not the patient has a diagnosis of one or more of the severe or disabling chronic conditions below.
Verification of Chronic Condition (VCC)
Plans using the CSNP pre-enrollment verification process have 30 calendar days to verify a qualifying chronic condition before needing to deny an enrollment request if verification is unsuccessful. This helps ensure that individuals who genuinely need specialized care are enrolled appropriately.
The Illness Self-Declaration Form can be used to request academic consideration for course work due to medical reasons, in lieu of a medical document. This form will automatically be forwarded to the instructor teaching the course to support your request.
In order to enroll in a chronic condition special needs plan, Medicare requires that your chronic condition be verified by your primary care provider or treating physicians office.
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