HEALTH CARE PROVIDER FORMCWU Student(Health Care Provider Completes This Section)
Your patient is requesting accommodations/academic adjustments in his/her CWU classes. The information you provide is critical to our ability to determine the appropriate services and/or accommodations, if any, for this student. Please be thorough in your evaluation as you complete the sections as it will help us assist your patient. Your timely completion of this form is essential to our ability to respond to your patient’s accommodation request.
Note: If you would rather provide your patient's medical information in traditional paper form, please feel free to fill out our Health Care Provider Statement Form (pdf). You may then email it as an attachment, fax it, or mail it to us. Our contact information can be found on our Home Page.
Please check all "major life activities" in which your patient experiences significant functional limitations due to a disability or disabilities:
Certifier Information and Authorization
Please provide the following information about the Medical Professional completing this form:
Note to Medical Professional: By providing the Certifier information above, you are confirming that the information contained in this document is true and accurate to the best of your knowledge.
Clicking the "submit" button will send this form electronically to:
Human Resources/Disability ServicesCentral Washington UniversityEllensburg, WA