Student Authorization:
I authorize Berklee Online to review my medical information for the purpose of medically withdrawing for this current semester. I
understand that this information will be handled in a confidential manner and in compliance with HIPAA. I acknowledge that the information
provided on this form is accurate as I know and understand it.
Note: Any student who borrowed under the Federal Direct Loan Program, are required to complete online federal Exit Counseling. This is an electronic form that can be completed at https://studentaid.gov/exit-counseling/.