Student Medical Authorization & Attending Physician’s Student Form - Complete Instructions and Statements

Sep 17, 2026

Student Medical Authorization & Attending Physician’s Student Form collects student and physician details needed to support a medical withdrawal claim. Part A provides completion and submission instructions, including providing an SSN or PIN and mailing the completed form to the Claims Department. Part B authorizes release of required health information and includes insured student identity, treatment history, and signatures. Part C documents physician certification of treatment and diagnosis, including ICD/DSM codes and dates. Part D covers assignment of benefits and includes fraud notices.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

PART A - INSTRUCTIONS

Completion and submission requirements

PART B - INSURED STUDENT AUTHORIZATION

Student and parent/guardian information

Authorization, treatment history, and signatures

PART C - ATTENDING PHYSICIAN’S STATEMENT

Patient certification and diagnosis

Codes and treatment dates

Physician questionnaire

PART D - ASSIGNMENT OF BENEFITS

Benefits assignment authorization

Fraud notice

| | STUDENT MEDICAL AUTHORIZATION & ATTENDING PHYSICIAN’S STUDENT FORM | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | PART A – INSTRUCTIONS | | | | | | | | | | | 1. READ AND COMPLETE THIS FORM. PLEASE PRINT CLEARLY. Incomplete forms may delay processing.
2. Remember to provide either your Social Security Number or your Personal Identification Number.
3. Be sure Parts B & C include the required signatures.
4. MAKE A COPY OF THIS FORM for your records. | | | | 5. Please mail this completed form to:
Tuition Secure c/o ASRM, LLC
Attention – CLAIMS DEPARTMENT
505 South Lenola Road, Suite 231 Moorestown, NJ 08057
6. Please call ASRM’s Claims Department at 1-800-359-7475 if you have any questions about this form. | | | | | | | PART B – INSURED STUDENT AUTHORIZATION (To be completed by student, parent or guardian) | | | | | | | | | | | INSURED STUDENT’S NAME (LAST, first, middle) | | | | | | | SSN or PIN | | | | STUDENT’S PERMANENT STREET ADDRESS | | | | CITY | | | STATE | | ZIP CODE | | PHONE NUMBER | | | | SCHOOL, COLLEGE OR UNIVERSITY NAME | | | | | | | HAVE YOU RECEIVED PRIOR TREATMENT FOR THE CONDITION CAUSING YOUR MEDICAL WITHDRAWAL (YES OR NO)? IF YES, PLEASE PROVIDE THE DATE OF THE LAST TREATMENT (MM/DD/YY). | | | | | | | | | | | I HEREBY AUTHORIZE my physician to complete the Attending Physician’s Statement and to release this and any other necessary health information to SiriusPoint America Insurance Company for use in verifying my claim for recovery of insured Program Fees as defined in the policy. All information provided is protected by the Health Insurance Portability & Accountability Act (HIPAA) and I understand that I may withdraw this authorization at any time by written notice to SiriusPoint America Insurance Company. | | | | | | | | | | | SIGNATURE (Student, if legal age, otherwise parent or legal guardian) | | | | | | | DATE (MM/DD/YY) | | | | PART C – ATTENDING PHYSICIAN’S STATEMENT (To be completed by physician) | | | | | | | | | | | I HEREBY CERTIFY that the Student named in Part B of this form has been a patient under my care and been treated for the medical condition(s) which have resulted in the Student’s complete withdrawal from the School, College or University in which they were attending. I further medically certify that the sickness or injury diagnosis prevents the Student from completing the rest of the current semester/term in which the Student is enrolled. | | | | | | | | | | | LICENSED PHYSICIAN SIGNATURE | | | PRINT NAME | | | | | DATE (MM/DD/YY) | | | LICENSE NUMBER | | PHYSICIAN EMAIL ADDRESS | | | | PHONE NUMBER | | | | | PHYSICIAN STREET ADDRESS | | | | CITY | | | STATE | | ZIP CODE | | Please provide the following information: | | | | | | | | | | | DIAGNOSIS | | | | | | | | | | | ICD CODE NUMBER | | | | DSM CODE \# | | | | | | | TREATMENT BEGIN DATE (MM/DD/YY) | | | | TREATMENT END DATE (MM/DD/YY) | | | | | | | FIRST CONSULTED DATE (MM/DD/YY) | | | | LAST CONSULTED (MM/DD/YY) | | | | | | | Please answer all of the following questions: | | | | | | | | | | | Is the Student still under your care for the condition described in the diagnosis (YES or NO)? | | | | | | | | | | | If referred to another physician, please provide the name and address: | | | | | | | | | | | If referred to you by another physician, please provide name and address of referring physician: | | | | | | | | | | | Has the withdrawal of this student been the result of abuse of alcohol or substance abuse disorders (YES or NO)? | | | | | | | | | | | Do you expect that the condition being treated will result in a Permanent Total Disability (a condition expected to last more than 60 months)? YES, NO or POSSIBLY | | | | | | | | | | | If the student’s condition has not r

FAQs

What information must be provided in Part A to avoid delays?

Complete and print the form clearly, provide either an SSN or a PIN, include required signatures in Parts B & C, and make a copy for records. Mail the completed form to the Claims Department listed on the form.

What does the insured student authorize in Part B?

The student (or parent/legal guardian) authorizes the physician to complete the Attending Physician’s Statement and allows release of necessary health information to SiriusPoint America Insurance Company to verify the claim. The authorization can be withdrawn by written notice to the company.

What must the attending physician certify in Part C?

The physician certifies the student was treated for the medical condition(s) that caused complete withdrawal and that the diagnosis prevents completion of the current semester/term. The form also requests diagnosis information, ICD/DSM codes, treatment dates, and answers to a physician questionnaire.

Sep 17, 2026

Uploaded by Sophia Brooks