I am requesting a medical leave of absence from Eastern Illinois University for the term specified above. I have requested that my medical treatment provider submit a written recommendation to the Office of Health & Counseling Services for consideration. I further acknowledge that my request must be approved by the Office of Health and Counseling Services. Simply filing this request form does not mean that a medical leave of absence has been granted. The Office of Health & Counseling Services will contact me at my EIU email account letting me know of their decision. If my request for a medical leave of absence is approved, it is my responsibility to work with each instructor to develop a course completion plan and to complete my coursework within one calendar year from the initial leave date. After one calendar year, any incomplete grades remaining from this term will change to a failing grade or the default grade supplied by the instructor. I understand that no refund of tuition, mandatory fees, and/or associated course charges will be issued if my request is approved.