MEDICAL DOCUMENTATION FORM
This form is to be completed thoroughly by the student and the student’s medical provider. This form
must be submitted to the University of Kentucky Registrar’s Office with the required documentation
detailed below. This form and documentation must be emailed directly from the medical providers
office to: tuitionappeals@uky.edu
or faxed to: 859-257-7160
Student’s Name: _______________________________ Student’s ID/SSN: _______________________
Semester Being Appealed: _______________________
To be completed by medical provider:
Please provide a signed letter on letterhead describing the medical/psychological condition of the
applicant and how it prevents them from performing academic duties. Academic duties are defined as:
attending class, studying course content, taking tests, and completing assignments. Please keep in mind
that students have FREE access to services and accommodations from University Health Services,
Counseling Center, Disability Resource Center, the Office of Residence Life, as well as numerous tutoring
sessions and other resources.
Medical Provider’s Name: __________________________ License #: __________________________
Licensed As: ______________________________________ State of Licensure: ________
Medical Provider’s Address: _____________________________________________________________
Medical Provider’s E-mail: __________________________________ Phone: _____________________
In addition, please answer the following questions below:
1. What date did this student first seek treatment? ______________________________
2. Date of Most Recent Visit: ___________________ Total Number of Visits: _______________
(Within the last 3 months)
3. Did this student’s condition/treatment require that they withdraw from the university during
the semester they are appealing? ____ Yes ____ No
4. Date when the student became unable to perform academic duties: ____________________
5. Is the student medically able to return to the University? ____ Yes ____ No
___________________________________________ _______________________
Medical Provider’s Signature Date
If the signed letter on letterhead or any of the above information is excluded, the student’s Tuition/Fees
Appeal will be rendered incomplete and a decision of denial will be made. All decisions from the
committee are final. If you have any questions, please contact: tuitionappeals@uky.edu
