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.)