Return from Leave of Absence Request Form

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Instructions

Clearance to return from a Leave of Absence (“LOA”) is required. Students should refer to the individualized terms of their leave letter and must complete all required evaluations or testing prior to return. Students on Administrative LOA, Personal LOA or Medical LOA must notify the School by the date indicated in the individualized leave of absence letter. If the School does not hear from you by this date, it will be assumed that you no longer wish to be considered in good standing and you no longer wish to continue your studies at the Icahn School of Medicine at Mount Sinai. Students will not be able to enroll in classes or clerkships with any outstanding holds on your account. All balances, such as tuition, housing and insurance, must be paid in full before you return.

Students on Administrative LOA, Personal LOA or Medical LOA must notify the School by the date indicated in the individualized leave of absence letter. If the School does not hear from you by this date, it will be assumed that you no longer wish to be considered in good standing and you no longer wish to continue your studies at the Icahn School of Medicine at Mount Sinai.

Students will not be able to enroll in classes or clerkships with any outstanding holds on your account. All balances, such as tuition, housing and insurance, must be paid in full before you return.

Student Information

Student Name*

First Name

Last Name

Life Number*

Home Address

Address Line 1

Address Line 2

City

State

ZIP Code

Home Phone

Cell Phone*

School email address*

Personal email address*

Degree Program*

Returning from Type of Leave:*

Returning to Year:*

Leave of Absence Start Date:*

Anticipated Return Date:*

Approval

Office of Student Financial Services:

TUITION and FEES: Students will be required to pay tuition at the new rates upon return. Any additional time in school will be subject to additional tuition and fees. Students must clear any housing arrears, in addition to any outstanding fees or tuition balances, in order to be cleared to return.

LOANS and FINANCIAL AID: The priority deadline for applying for financial aid is May 1. Please contact the Office for Student Financial Services for any questions.

HEALTH INSURANCE: Students who dropped school health insurance must re-sign within 30 days of their return date. Please contact the Office for Student Financial Services for any questions.

I have spoken with the Office of Student Financial Services and acknowledge I understand the conditions above.*

Yes

Compliance:

In order to begin clinical rotations in clerkship years or to participate in ASM clinical activities after the end of your leave, you must meet the medical schools and our affiliates’ compliance requirements. Please navigate to the Medical Student Compliance Organization in Blackboard for your class appropriate check list with due dates. For any questions, email compliance@mssm.edu. If you do not do so, you will not be permitted to return.

I acknowledge I understand the timeline to complete compliance requirements and the conditions above.*

Yes

Housing:

Students must reapply for housing accommodations at the same time requesting readmission. To fill out the appropriate paperwork, please reach out to housing@mountsinai.org. Further information about the housing policy can be found at: http://icahn.mssm.edu/education/students/housing

Do you plan to return to Sinai housing?

Yes No

International Students:

Are you an International Student?

Yes No

I attest I have spoken with and received clearance from the International Personnel Office to return.

Yes

Student Agreement

I understand that to return, I must receive written approval and abide by all deadlines from the School.

I have read, understand, and agree to the terms above.*

Yes

Signature

[clear]

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Financial Aid Approval

Approve Deny

Billing Approval

Approve Deny

Health Insurance Approval

Health Approval

Approve Deny

Compliance Approval

Approve Deny

Housing Approval

Approve Deny

International Students

International Students Approval

Approve Deny

Deans/Program Director Approval

Approve Deny

Registrar Approval

Approve Deny