CNS Stimulant Cap Removal Request

Student VIP utilizes a CNS Stimulant Cap to prevent misuse of medications. We request a physician's consent to lift CNS Stimulant Caps to ensure that those students who cannot live without these medications are covered up to their overall drug or extended health plan maximum(s).

Note that the student & physician will receive an e-mail once this request has been sent and again when it has been processed.

Student Information

School/Policy # *

Student ID Number *

Student Name * First Last

Student Email *

Physician Information & Reason for Request

Location of Medical Clinic *

Name of Physician Requesting Change * First Last

Physician's Contact E-mail Address *

Reason for Requesting Removal of Cap *