Sample Request For Medical Information printable pdf download

SAMPLE ‐ Request for Medical Information

Dear Dr. [name]:

[Employee name] a patient of yours, is employed as a [classification] with the [agency]. I received your

[letter / statement] dated [date], wherein you indicated [insert relevant information]. Enclosed,

please find a release signed by [employee name] which authorizes you to provide information regarding

[his or her] current condition and any resultant limitations. I will use your information in evaluating [his

or her] ability to perform the functions of [his or her] position and in determining whether

accommodations in [his or her] work environment, schedule, or assignments are required and feasible.

Please provide your analysis of [employee’s name] residual functional capacity and specifically

comment on the following: [Insert questions about employee’s ability to perform the essential

functions of his job. Using Maintenance Worker as the example, such activities could include, but

would not be limited to: gross and fine finger motions required for minor repairs such as carpentry,

painting, plumbing, electrical and masonry work; grip strength, lifting and carrying ‐ how far ‐ how

often, weight limits; and any other applicable maintenance work ‐ including work on any special

events and seasonal functions that might impact his upper extremity function.]. I have enclosed a

functional capacity assessment form and narrative which outlines the duties and responsibilities of

[employee name]’s position. Please describe in detail any limitations or restrictions on [his or her]

ability to perform the essential functions of [his or her] position and list any assistive devices,

equipment, or any accommodation you believe would enable [employee name] to perform [his or her]

duties and responsibilities.

To preserve confidentiality, please ensure that your response is sealed in the enclosed self‐addressed,

postage‐paid envelope. If you have any questions or require additional information, please contact me

at [telephone number].

Sincerely,

[Authorized Signature]

Enclosures [enclose copy of release form signed by employee, narrative of job duties, functional

capacity assessment form, and envelope.]

c: [Employee’s name]

Authorization for Release of Information

I, [employee name], hereby authorize [physician’s name], to furnish written information to [employer

name & title], my employer, regarding my residual functional capacity, any limitations or restrictions on

Sample Request For Medical Information