Letter Requesting Documentation For Determining Ada Eligibility From A Medical Provider
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6State of Minnesota –
[Agency Name]
Letter Requesting Documentation for Determining
ADA Eligibility from a Medical Provider
Genetic Information Nondiscrimination Act of 2008 Disclosure: This authorization does not cover, and
the information to be disclosed should not contain, genetic information. “Genetic Information”
includes: Information about an individual’s genetic tests; information about genetic tests of an
individual’s family members; information about the manifestation of a disease or disorder in an
individual’s family members (family medical history); an individual’s request for, or receipt of, genetic
services, or the participation in clinical research that includes genetic services by the individual or a
family member of the individual; and genetic information of a fetus carried by an individual or by a
pregnant woman who is a family member of the individual and the genetic information of any embryo
legally held by the individual or family member using an assisted reproductive technology.
Date:
To: Medical Provider Name
Medical Provider Address
RE: Employee Name
Date of Birth
The above employee has requested a reasonable accommodation under the Americans with Disabilities
Act (“ADA”), as amended, to enable the employee to perform the essential functions of his/her position.
The information requested on this form will assist us in making a determination regarding the
employee’s request. An Authorization for Release of Medical Information is attached to this document.
INSTRUCTIONS: Please complete the following form and have it signed by the employee’s attending
health care provider. Attach additional pages as needed. Do not provide information not related to the
employee’s ability to perform his/her job duties. For example, do not identify the impairment if it does
not have an impact on the employee’s ability to do his/her job. Please do not send copies of medical
records. We are not authorized to have medical records and are not qualified to interpret them.
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