Medical Housing Exception Information and Application Bellarmine University Residential Living Policy: On-campus residence affords students added opportunity to become fully involved in college life. All fulltime students with 89 or less credit hours must live in the residence halls or with a local parent/legal guardian (within a 50 mile radius of the university). Those students 22 years of age or older are exempted from the policy. Exceptions may be made in special cases, but must have prior approval from the Director of Housing and Residence Life. If a student does not live either with a parent/legal guardian or in the halls and has not applied for an exception, the student may be subject to judicial sanctioning from the University and/or housing fines. Exception Process: All documentation will be submitted to the Director of Housing and Residence Life. The Director will make a decision of approval or denial based on submitted documentation. Instructions: Students wishing to request a release from the Residential Living Policy may do so by following the steps below: Complete the Exception Application form Submit the completed form, student letter of request, all required information, and the checklist of completion to the Housing and Residence Life Office by due date Circumstances: Students wishing to request a housing exception may do so under the following circumstances: Commuting: Residing with Parents/Legal Guardian Financial Hardship Documented medical condition Other extenuating circumstances: Other reasons that may not fall into one of the areas listed above. Please fully explain the nature of the situation and provide any supporting documentation. Procedures: At the time a student submits the form, he/she may request an appointment to meet and discuss his/her request with Director of Housing & Residence Life. If no appointment is made, the request will be reviewed based on the written documentation submitted. The Director will make a decision within five to seven (5 to 7) business days after meeting or following the receipt of the documentation and will notify the student via email to his/her BU email address. Appeal: Students may make a written appeal within three business days of being informed of the Director’s decision. Appeals are made to the Appeal Committee which includes: The Directors of Financial Aid, Food Service, Admissions, Disability Services and Health Services. All appeals are to be made in writing. The Petition to Appeal Form must be completed. Appeals must be based on one or more of the following: Presence of new documentation Further explanation of situation Other extenuating circumstances Medical Housing Exception Application Name: ___________________________________ Student ID# _____________________ Permanent Address: ____________________________________________________________________ Street City State Zip Cell Phone Number: _________________ Requesting exception for: □ Fall 20___ □ Spring 20___ Academic Information: Credit hours earned: _____ GPA: _______ Major: ______________ Housing Information: □ New/Have NOT applied for housing □ Applied/Assigned but not checked-in □ Currently living in _______________ Hall/Room # Circumstances/Procedures Detail---All Applications must include a typed student letter of explanation. □ Commuting: Residing with parent/ legal guardian Required Documentation: Completed verification of Living with Parents Form □ Financial hardship Significant financial hardship that would place an excessive strain on the student’s financial situation and prevent the student from attending Bellarmine University if required to live in the residence halls. Financial savings is not a valid request for financial hardship. Required Documentation: Financial Hardship Worksheet Filed FAFSA with Estimated Family Contribution documented in student letter from current and previous year Student’s award of financial aid through the Bellarmine University Financial Aid Office □ Medical Medical condition that requires special living accommodations that the residence halls cannot reasonably provide. Required Documentation: Authorization for Release of Confidential Information Provider Report Form Written Medical Provider Assessment □ Other ______________________ For all other requests, the student must prove a need for which the residence halls cannot reasonably provide and requires special off-campus living arrangements. Required Documentation: Any documentation verifying the student’s need and why that need cannot be met on campus would be required. Medical Authorization for Release of Confidential Information Student Name: _____________________________ Student ID# ____________________ Physician/Therapist Name: _____________________________________ Physician/Therapist Contact Phone# __________________________ In order for the Director of Housing and Residence Life and the Appeal Committee (if applicable) to objectively evaluate your exception request, additional details might be needed from your health care provider, the treating physician. We cannot accept documentation from parents. By signing this form, you understand that your health care provider has the right to disclose any information directly to the Housing and Residence Life Office that is necessary to assist with the exception review process. This authorization shall remain in effect for: _____ Thirty (30) days _____ Sixty (60) days _____ Ninety (90) days I understand that the information used or disclosed as a result of this authorization may be re-disclosed by the recipient and is no longer protected by HIPAA Privacy Rules. You have the right to revoke this authorization, in writing anytime by sending written notification to the Director of Housing and Residence Life. ___________________________________________________________________________ Printed Name of Student Witness Signature ___________________________________________________________________________ Signature of Student Date Medical Treating Physician Report Form In order for the Director to objectively evaluate the need for housing or dining exception requests, please provide detailed information related to the medical/psychological condition of the student. Please send a written assessment on clinical letterhead, which includes the initial on-set of the condition, type, frequency and severity of symptoms, and treatments or medications necessary to alleviate symptoms. In addition, please outline the type of living environment, dietary restrictions, special dietary needs, or any additional amenities that the student might need in order to enhance their quality of living and/or meet their needs. Physician/Therapist Name: ___________________________________ Student Name: ________________________________________________ Date of First Visit: ____________________ Date of most recent visit: ___________________ NOTE: This form is to be completed by the student’s physician/mental healthcare provider (treating physician) and either faxed to 502-272-7019 or mailed directly to the following address: Bellarmine University Housing and Residence Life Office, 2001 Newburg Rd., Louisville, KY 40205. Attention: Leslie Maxie-Ashford, Director of Housing & Residence Life. *We asked that if a parent is the treating physician, that another opinion about treatment is gathering for this form submission. In addition, please answer the following questions below: _____ Yes _____ No Has there been a substantial decline of the student’s original medical/psychological condition within the last three months? If yes, please check any or all the following observations within the last three months: _____ Increase in the number of symptoms _____ Increase in the severity of symptoms _____ Persistence of symptoms _____ Decreased functional impairment _____ Increase in the subjective level of client distress _____ Yes _____ No If applicable, has the student been tested for allergies as part of their evaluation of the above? If yes, please provide date of testing and attach results. Please note: Food allergies require a detailed list be submitted of the food items that the student can/cannot tolerate. Allergies resulting in rhinitis or bronchial asthma require recommendation for appropriate living environment (i.e. air-conditioning, controlled environment, air purifier, etc.)