Sample Letter To Document Disability From Primary Care

Summary

Sample Letter to Document Disability
From Primary Care Physician
To Vocational Rehabilitation
www.hrtw.org
Date
TO: NAME OF VR COUNSELOR
Office of Rehabilitation Services
ADDRESS
CITY, STATE
FROM: DOCTOR’s NAME (its better if this is on the physician’s letterhead)
RE: John (XXXXXX) XXXXXXX, Age 18, DOB XX/XX/1986
Phone: XXX-XXX-XXXX
Graduate of XXXXXX High School as of June 9, 2004
Dear NAME OF VR COUNSELOR,
The purpose of this letter is to document significant chronic health conditions that impair activities of daily living for
XXXXXXX – XXXXXX. I have been his primary care physician for18 years

XXXXXX’s health issues and their effect on school and potential employment do meet the definition of disability by
Utah’s Vocational Rehabilitation criteria [Title 53A Chapter 24, 102(3)] and ADA and Section 504 requirements (see
fact sheet on last page)

SIGNIFICANT HEALTH IMPAIRMENTS
• Endocrine System - TYPE ONE DIABETES
• Digestive System - ULCERATIVE COLITIS
• Immune System - ANKYLOSING SPONDYLITIS
CONFIDENTIALITY SAFEGUARDS - In compliance with HIPAA confidentiality mandates permission for this personal
health information has been obtained by the patient, and as such this letter should be treated as highly confidential
records and not shared without the patient’s permission

What follows is an overview of the health issues that XXXXXX lives with. Enclosed are relevant reports and findings
of recent and past health related medical testing

TRAINING FOR EMPLOYMENT & IMPORTANT OF HEALTH CARE BENEFITS
It is important to consider what XXXXXX could do to meet his potential, live independently, and remain as healthy
as possible. XXXXXX is a very bright young man who has displayed numerous talents in music, art, writing,
literature, and science

Given his educational performance, intellectual abilities and aspirations, he certainly has the potential to do well in
competitive employment through post-secondary college courses – if supported. It will be essential that career
development be aimed at stable; well-paying jobs that offer comprehensive benefits to assure maintain health
status and financial independence

In sum, I believe that offering XXXXXX financial and technology support through the Office of Rehabilitative
Services would ensure not only employability but also would support all important aspects of independent living
and optimal quality of life. Please contact me if you require further information

Sincerely,
XXXXXXXXX, M.D

XXXXXX XXXXXX Chronic Health Issues
1. TYPE ONE DIABETES, ICD-9 CODE: 250.01, Diagnosed: 1998; age 12 years
Health Impact to XXXXXX – He requires daily insulin, strict dietary management, and daily/hourly
monitoring and management of blood sugar levels. He has been hospitalized several times, either for
severe hypoglycemia or ketoacidosis

2. ULCERATIVE COLITIS, ICD-9 CODE: 556.9, Diagnosed: Diagnosed 2000; age 14 years
XXXXXX required surgery for this. He had a colectomy

Health Impact to XXXXXX – Although he technically no longer has ulcerative colitis due to the absence of a
colon, he continues to suffer from acute episodes of pouchitis. Symptoms, including steadily increasing
stool frequency that may be accompanied by incontinence, bleeding, fever and/or feeling of urgency. Most
cases can be treated with a short course of antibiotics. Additionally, absence of a colon causes problems
with nutritional absorption and is associated with XXXXXX’s below-average weight

3. ANKYLOSING SPONDYLITIS, ICD-9 CODE: 720.0, Diagnosed: 2000; age 14 years
Health Impact to XXXXXX – his degenerative spinal arthritis that causes episodes of severe pain and
limitations on his physical capabilities, requiring medication and a physical therapy regime for
management

ACCOMODATIONS REQUIRED – SCHOOL /EMPLOYMENT TRAINING/PREPARATION
In order to maximize XXXXXX’s performance level that will not jeopardize health status, some accommodations and
modifications are required:
1. DAILY MONITORING- XXXXXX’s diabetes management requires that he be able to take frequent breaks when
the need arises to a) treat low blood sugars, b) use the restroom, c) test his glucose levels, and d) administer
insulin. Although XXXXXX’s diabetes management has been relatively stable, the presence of additional
autoimmune diseases puts his future diabetes management and long-term health at risk

2. WATER INTAKE & BATHROOM BREAKS - XXXXXX’s lack of a colon causes him to use the restroom frequently,
and he must drink a large amount of water throughout the day to prevent dehydration

3. LIMIT PHYSICAL EXERTION - His ankylosing spondylitis causes him days with severe back pain, making
rigorous activity very painful. Tasks requiring heavy lifting or having to sit or stand for a prolonged period of
time without breaks exacerbate his condition and are harmful to his spine. Class schedules and location of
classrooms, time needed to change travel to next class need to be evaluated. There may be a need for
additional accommodations in the future, such as mobility assistance, elevator use, use of laptop or cell phone
to alleviate unnecessary physical travel

4. ATTENDANCE - Episodes of severe hypoglycemia or ketoacidosis, pouchitis infections, and severe spinal pain
can result in XXXXXX’s need for additional sick days to treat the accompanying fever, diarrhea, and abdominal
pain. Teachers will need to allow for increased time to make up schoolwork or other forms of instruction if
absenteeism is due to noted health issues

5. ACCOMODATIONS - XXXXXX has had a 504 plan in place at school (K-12) to ensure these accommodations
have been allowed. The individualized employment plan / individual written rehabilitation plan, that will be
developed between VR and XXXXXX will need to specify needed accommodations. While in college, XXXXXX
will need to coordinate accommodations (health, learning and testing) for maximized performance with the
Disability Resource Centers on campus

Sample Letter to Document Disability From Primary Care Physician To Vocational Rehabilitation Date TO: NAME OF VR COUNSELOR Office of Rehabilitation Services ADDRESS CITY, …

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Frequently Asked Questions

What is a disability letter from doctor?

A disability letter from doctor is a document that outlines the extent of an individual's physical or mental impairment. This document is often required when applying for social security benefits, vocational rehabilitation services, or other government assistance programs.

How do i create a sample disability letter?

Select the document you want to sign and click Upload. Choose My Signature. Decide on what kind of signature to create. There are three variants; a typed, drawn or uploaded signature. Create your signature and click Ok. Press Done. After that, your sample disability letter is ready.

How to write a letter to a doctor with a address?

ADDRESS CITY, STATE FROM: DOCTOR’s NAME (its better if this is on the physician’s letterhead) RE: John (XXXXXX) XXXXXXX, Age 18, DOB XX/XX/1986 Phone: XXX-XXX-XXXX Graduate of XXXXXX High School as of June 9, 2004