Letter Requesting Documentation For Determining Ada Eligibility From A Medical Provider Page 6

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Medical Inquiry Form in Response to an ADA Reasonable Accommodation Request
Page 5
Please return the completed form to the ADA Coordinator at
[Agency]
at the following fax number:
If you experience difficulty faxing this form, please call:
[ADA Coordinator]
at the following phone number:
Thank you in advance for your prompt reply to the questions in the attached provider
questionnaire.
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.

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