Sample Letter from Health Care Provider: for a leave of absence

Supporting Need for Accommodation Under ADA or FEHA

Leave of Absence

Your Health Care Provider’s Letterhead


To Whom It May Concern:

I am the treating [job title or description, such as physician, psychiatrist, psychologist, therapist, social worker, case worker, or health care professional] for [name of employee or applicant]. 

[Name] has [optional:  name or description of employee’s medical condition,] a medical condition that [substantially*] limits [Name]’s major life activities, including [fill in relevant major life activities, such as:  caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, or the operation of major bodily function]. 

As a result of [Name]’s disability, [she/he] is temporarily unable to work.  [She/he] needs a leave of absence for treatment and recovery.  This leave [began on/is scheduled to begin on] [date leave is to begin].

I anticipate that [Name] will be able to return to work on [date].** 

Signature and license number