Dickinson College Student Health Service
Request for exemption from Automobile Restriction Policy
To be completed by the studentís health care provider.
Your patient has requested special permission to have a car on campus ďfor medical reasonsĒ during his/her freshman year.† Dickinson College Student Health Services has a fully staffed medical clinic.† Staffing consists of nurse practitioners with prescriptive privileges, a registered nurse, and physician coverage 3 hours per week with telephone consultation as needed. We have a CLIA certified moderate complexity lab, and are nationally accredited by the Accreditation Association for Ambulatory Health Care (AAAHC). With this in mind, please provide the following information regarding your patientís special request. †Thank you very much for your time.
If yes, please explain. ______________________________________________________
How frequently do you anticipate this patient needing to travel home for
this special care?†
Please feel free to add any additional information you feel† may be helpful.†
Thank you again for your time.
Health Care Provider's signature, address & phone number
Please return via fax to 717-245-1938,or
mail to:††Mary Arthur CRNP, MPA, Director Student Health Services
Dickinson College P.O. Box 1773 Carlisle, PA 17013†††