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This letter further authorizes OEO to speak to my treating physician or health care provider directly in regards to any questions s/he may have with respect to my condition that relates to  \nmy request for accommodations.  \nI understand that the requested data is for the above-mentioned purposes, and that I may refuse to provide the requested medical information. However, I understand that if I refuse to provide the information, the University may refuse to provide reasonable accommodation.  \nPatient Signature/Tufts University Student Date  \n*This form is not used for academic or classroom accommodations. Students should contact the StAARCenter or their appropriate graduate School's Student Services Office for academic-related accommodation requests.  \n196 Boston Avenue, 4th floor, Medford, MA 02155 |Tel: 617 .627.3298| FAX: 617 .627.3150|WEB: [oeo.tufts.edu](oeo.tufts.edu)  \nOffice of Equal Opportunity  \nAttention Medical Practitioner:  \nThe student named below has indicated that they have a disability or medical condition andwill require reasonable accommodation(s) to participate in a program or activity at Tufts University.  \nIn order for Tufts to proceed, we require additional information and are enclosing with this medical form (Accommodation Authorization for Release of Medical Information) so that the student is fully informed of what we are asking and can approve the release of the information needed. The American with Disabilities Act (ADA) requires the provision of reasonable accommodations to those who are disabled, i.e. , have a medical condition that substantially limits a major life function. We are requesting the following information to determine if the student is covered under the ADA, and if so, an explanation of the nature of the condition specific to which major life activities the condition limits. The information that you provide will be used to better understand the nature, severity and treatment plan for the student’s diagnosis and the appropriateness of requested accommodations or services. Please note that the information you provide must be current; in general, you must have seen the student within the last 6 months to meet this requirement. If you have recently begun treating this student you may find that you do not yet have sufficient information to respond to the questions on this form. If you have not had recent clinical contact with the student, or otherwise find that you cannot effectively complete this form, please inform the student directly. Please make sure to complete this form in its entirety.  \nPlease return the completed signed forms or send them by fax (please adhere to HIPAA regulations and call before faxing) to Tufts University, Office of Equal Opportunity, at the following address/fax number:  \nTufts University  \nOffice of Equal Opportunity  \n196 Boston Avenue, Suite 4000B Medford, MA 02155  \nFax: 617.627.3075 Phone: 617.627.3298  \nIf you have any questions or concerns about this form, please contact the Accommodations [Team at ](Team at Accommodations.OEO@tufts.edu)[Accommodations.OEO@tufts.edu](Team at Accommodations.OEO@tufts.edu).  \n196 Boston Avenue, 4th floor, Medford, MA 02155 |Tel: 617 .627.3298| FAX: 617 .627.3150|WEB: [oeo.tufts.edu](oeo.tufts.edu)  \n1. Student/Patient Name:    \n2. Date of your last clinical contact with the student/patient:    \n3. Nature of studen","cbCaidbbK3BDYlog","https://ap.wps.com/l/cbCaidbbK3BDYlog","pdf",447536,"English","# Accommodation Authorization for Release of Medical Information\n## Request purpose and consent to disclose\n## Medical practitioner instructions and required timeframe\n## Provider return instructions (address, fax, phone)\n## Form fields: student/provider details\n## Form fields: disability nature, onset, status, impacts\n## Form fields: major life activities and limitations\n## Form fields: treatment, prognosis, symptom patterns\n## Form fields: recommended accommodations\n## Notes and HIPAA guidance","[{\"question\":\"Who can receive the medical information and for what purpose?\",\"answer\":\"Tufts University Office of Equal Opportunity may receive the requested information to evaluate the request for a reasonable accommodation under Tufts accommodation policies and applicable law.\"},{\"question\":\"Does the form require the student/patient to provide medical information?\",\"answer\":\"The authorization states the student/patient may refuse to provide requested medical information, but refusal may lead the University to deny reasonable accommodation.\"},{\"question\":\"What is expected from the medical provider in completing the form?\",\"answer\":\"The provider should give information about the nature, severity, treatment plan, ADA coverage, and how conditions affect major life activities; information must be current, and the provider generally should have seen the student within the last 6 months.\"}]","Accommodation Authorization for Release of Medical Information | PDF",1790794775]