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.

Patientís† name† ††________________________________ Date of Birth _____________

Medical reason for which the student is asking for an exemption: ________________________

Is traveling home for medical care NECESSARY?††
†††††††††††††

Yes No

If yes, please explain. ______________________________________________________

How frequently do you anticipate this patient needing to travel home for this special care?†
___________________________________________________________________________

Do you feel your patient could be provided equivalent care at the Student Health Center if providers called you for consultation as needed?
Yes No

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†††