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ADA Documentation Request
This must be filled out by your medical provider, trying to fill this form out yourself will result in denying all requested accommodations.
Applicant / Employee Name
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Provider filling out form
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E-mail address of practice
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Phone Number of Practice
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Your patient (who sent this link to you or your office) has requested accommodations beyond what we normally offer a qualified disabled person. Can you verify that your patient has a medical condition that creates the need for the accommodation?
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A
Yes
B
No
Do you have any specific recommendations regarding possible accommodations to enable this patient to successfully compete for employment?
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A
Yes
B
No
If so, what do you suggest?
How would these suggestions help your patient? Help me justify the costs of the accommodation to my team?
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Providers Signature
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Signature
Today's Date
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Submit