/For Students/Documentation Guidelines/Provider Documentation Form

Provider Documentation Form

Licensed health care professionals may use this form to share documentation with ARS. Documentation must substantiate the fact that the condition (disability or chronic medical condition) is present, limiting a major life activity or major bodily function with impacts upon functioning.

Please see our Documentation Guidelines for more thorough information, including guidelines for documentation supporting an Emotional Support Animal request.

Provider Documentation

Professional Clinician/Provider Information

Professional's Name

Professional's Occupation

Professional's Email

Used to provide you with a copy of this submission for your records and for verification and clarification purposes.

Professional's Phone Number

Practice or Business Name

Professional's NPI# and/or relevant professional license numbers

Please select 'Yes' to indicate that you are submitting this information and documentation in accordance with and within the scope of any applicable, professional Codes of Ethics

Yes

Other - Please elaborate

"Other" selected - Please elaborate

The Applicable Professional Body / Code of Ethics

For example the American Board of Pediatrics, American Medical Board, American Psychological Association, American Counseling Association, etc.

Your Client/Patient (the student)

Client/Patient's First Name

Client/Patient's Last Name

If known, your client's/patient's UNC "PID Number"

This is a nine-digit student ID number assigned by UNC.

Client / Patient's Date of Birth

Client / Patient's Email

Professional Contact with your Client / Patient

Initial Meeting Date

Most Recent Meeting Date

Frequency and number of office visits in the last 12 months

Diagnosis 1

Primary Diagnosis

ICD / DSM Code

If the condition is temporary, how long is the impact anticipated to last?

Diagnosis 2

ICD / DSM Code

If the condition is temporary, how long is the impact anticipated to last?

Diagnosis 3

ICD / DSM Code

If the condition is temporary, how long is the impact anticipated to last?

Diagnosis - Other

Other diagnoses

Diagnostic Information

Diagnostic Methodology

Select all that apply.

Clinical Interview (structured or unstructured)

Developmental History/Interview(s) with other persons (e.g., parent, teacher, therapist)

Behavioral Observation(s)

Psychoeducational or Psychological Assessment (attach document)

Medical Tests (attach document)

Other (please specify, e.g. involvement of other professionals)

Other Methodology - Please specify

Please attach any relevant documentation.

Document 1

Choose File

Document 2

Choose File

Document 3

Choose File

Current Impact and Functional Limitations

Please provide specific information about the functional limitations and impacts of the disability or chronic medical condition experienced by the student along with information about the level of severity, frequency and duration of the impacts if applicable as they pertain to the academic and/or residential settings.

Recommended Accommodations

Recommendations are welcomed and considered, however ARS makes the ultimate determination on eligibility and reasonable academic adjustments necessary to provide equal access for participation in academic courses, programs and activities. Recommendations should be directly linked to the impact or functional limitations associated with the disability, or medication prescribed to control symptoms and include a clear rationale based on level of impairment.

Sharing and printing options: