Reasonable Accommodation Medical Documentation Request Letter PDF

Generate a concise letter to your provider outlining job duties, needed documentation, and an authorization to share functional limitations without extra medical details.

Provider name

Clinic (optional)

Provider address line 1

Provider address line 2 (optional)

Patient / employee

Date of birth (optional)

Phone

Employer

HR contact (optional)

Documentation deadline

Job title

Essential functions

Limitations summary

Requested accommodations (one per line)

Attachments (one per line)

Include plain-English authorization language

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