Sample Letter From Health Care Provider: For Any Needed Accommodation

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] seeks an accommodation from [employer]. 

[Describe situation and how accommodation will assist employee by enabling him/her to perform job or to maintain health.]

[Name] will require this accommodation from [Start Date] to [End Date] with a possible need for extension upon evaluation.

[Example 1] As a result of [Name]’s disability, she occasionally experiences episodes of disorientation and dizziness.  During these episodes, [Name] must sit or lie down for a few minutes to recover.  Therefore, [Name] needs, as an accommodation, permission to take these short breaks.

[Example 2] As a result of [Name]’s disability, [she/he] is extremely sensitive to distractions, including noise, colors and light.  When these distractions are present, [Name] has difficulty concentrating on [his/her] job.  Therefore, [Name] needs, as an accommodation, a workspace in which these distractions are reduced.

Signature and license number *Federal law (the ADA) requires that the condition “substantially limit” a major life activity.  State law (the FEHA) requires that the condition “limit” a major life activity.