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Department of State Academic Exchanges Participant Medical History and Examination Form Having been selected to participate in a U.S. Department of State educational exchange program, you are required.

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How to fill out the PDF Form - Fulbright Program For Foreign Students - Laspau Harvard online

Filling out the Fulbright Program for Foreign Students PDF form is a crucial step in your educational exchange journey. This guide provides a comprehensive overview of each section and field of the form, ensuring that you complete it accurately and efficiently.

Follow the steps to successfully complete your form.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Begin with Part I, where you will fill out your personal information. Provide your full name, date of birth, and present address. If known, include your grant location and grant dates.
  3. Indicate whether you will have private health insurance during your program. If yes, fill in the health plan details, including the provider's name, health plan ID, and effective date.
  4. List any medical professionals you have consulted in the past three years, including your primary care physician and any specialists. Ensure you include their specialties and contact numbers.
  5. Complete the emergency contact information. Provide the names, addresses, and phone numbers of two emergency contacts.
  6. Consider appointing a medical proxy. If you have one, provide their details and any relevant documentation.
  7. Part II requires your physician to fill out your medical history. Ensure that your physician is aware of all past and current health conditions.
  8. In Part III, your physician will conduct a physical examination and complete the evaluation based on the examination results. Make sure they provide all requested information.
  9. Ensure that the form is signed by your physician and that all parts are accurately completed before submission.
  10. Once your form is fully completed, save the changes, and download, print, or share the document as necessary.

Start filling out your Fulbright Program form online today to ensure your application is processed smoothly.

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APPLICATION INSTRUCTIONS FOR FULBRIGHT GRANT ...
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Definition of an Attestation Statement: In order for an attestation statement to be considered valid for Medicare medical review purposes, the statement must be signed and dated by the author of the medical record entry and contain the appropriate beneficiary information.

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