Disability Letter From Doctor PDF Details

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. The letter should be concise and easy to understand, and it should include information about the individual's diagnosis, prognosis, and functional limitations. In most cases, the doctor who writes the letter will be asked to provide details about how the impairment affects the patient's ability to work and live independently.

We have compiled some general details about the disability letter from doctor. You might want to find out its length, the average time needed to prepare the form, the blanks you will need to fill in, and so forth.

Form NameDisability Letter From Doctor
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesdoctor disability letter, letter sample disability, disability doctor letter, letter disability form

Form Preview Example

Sa m ple Le t t e r t o D ocu m e n t D isa bilit y

Fr om Pr im a r y Ca r e Ph y sicia n

To V oca t ion a l Re h a bilit a t ion


w w w . hr t w . or g

Dat e





Office of Rehabilit at ion Ser v ices






DOCTOR’s NAME ( it s bet t er if t his is on t he phy sician’s let t er head)


John ( XXXXXX) XXXXXXX, Age 18, DOB XX/ XX/ 1986




Gr aduat e of XXXXXX High School as of June 9, 2004


The pur pose of t his let t er is t o docum ent significant chr onic healt h condit ions t hat im pair act iv it ies of daily liv ing for XXXXXXX – XXXXXX. I hav e been his pr im ar y car e phy sician for 18 y ear s.

XXXXXX’s healt h issues and t heir effect on school and pot ent ial em ploy m ent do m eet t he definit ion of disabilit y by Ut ah’s Vocat ional Rehabilit at ion cr it er ia [ Tit le 53A Chapt er 24, 102( 3) ] and ADA and Sect ion 504 r equir em ent s ( see fact sheet on last page) .


Endocr ine Sy st em - TYPE ONE DI ABETES

Digest iv e Syst em - ULCERATI VE COLI TI S

I m m une Sy st em - ANKYLOSI NG SPONDYLI TI S

CONFI DENTI ALI TY SAFEGUARDS - I n com pliance w it h HI PAA confident ialit y m andat es per m ission for t his per sonal healt h infor m at ion has been obt ained by t he pat ient , and as such t his let t er should be t reat ed as highly confident ial r ecor ds and not shar ed w it hout t he pat ient ’s per m ission .

What follow s is an over view of t he healt h issues t hat XXXXXX liv es w it h . Enclosed ar e r elev ant r epor t s and findings of r ecent and past healt h r elat ed m edical t est ing.


I t is im por t ant t o consider w hat XXXXXX could do t o m eet his pot ent ial, liv e independent ly , and r em ain as healt hy as possible. XXXXXX is a v er y br ight y oung m an w ho has displayed num er ous t alent s in m usic, ar t , w r it ing,

lit er at ur e, and science.

Giv en his educat ional per for m ance, int ellect ual abilit ies and aspir at ions, he cer t ainly has t he pot ent ial t o do w ell in com pet it ive em ploy m ent t hr ough post - secondar y college cour ses – if suppor t ed. I t w ill be essent ial t hat car eer dev elopm ent be aim ed at st able; w ell- pay ing j obs t hat offer com pr ehensiv e benefit s t o assur e m aint ain healt h

st at us and financial independence.

I n sum , I believ e t hat offer ing XXXXXX financial and t echnology suppor t t hr ough t he Office of Rehabilit at iv e

Ser v ices w ould ensur e not only em ploy abilit y but also w ould suppor t all im por t ant aspect s of independent living and opt im al qualit y of life. Please cont act m e if y ou r equir e fur t her infor m at ion .

Sincer ely ,


Et c.



Ch r on ic H e a lt h I ssu e s

1 .

TYPE ON E D I ABETES, I CD- 9 CODE: 250 . 01, Diagnosed: 1998; age 12 y ear s


Healt h I m pact t o XXXXXX – He r equir es daily insulin, st r ict diet ar y m anagem ent , and daily / hour ly


m onit or ing and m anagem ent of blood sugar lev els. He has been hospit alized sev er al t im es, eit her for


sev er e hy pogly cem ia or k et oacidosis.


2 .

U LCERATI V E COLI TI S, I CD- 9 CODE: 556 . 9, Diagnosed: Diagnosed 2000; age 14 y ear s


XXXXXX r equir ed sur ger y for t his. He had a colect om y .


Healt h I m pact t o XXXXXX – Alt hough he t echnically no longer has ulcer at iv e colit is due t o t he absence of a


colon, he cont inues t o suffer fr om acut e episodes of pouchit is. Sy m pt om s, including st eadily incr easing


st ool fr equency t hat m ay be accom panied by incont inence, bleeding, fev er and/ or feeling of ur gency . Most


cases can be t r eat ed w it h a shor t cour se of ant ibiot ics. Addit ionally , absence of a colon causes pr oblem s


w it h nut r it ional absor pt ion and is associat ed w it h XXXXXX’s below - aver age w eight .

3 .

AN KYLOSI N G SPON D YLI TI S, I CD- 9 CODE: 720 . 0, Diagnosed: 2000; age 14 y ear s


Healt h I m pact t o XXXXXX – his degener at iv e spinal ar t hr it is t hat causes episodes of sev er e pain and


lim it at ions on his physical capabilit ies, r equir ing m edicat ion and a phy sical t her apy r egim e for


m anagem ent .



I n or der t o m ax im ize XXXXXX’s per for m ance lev el t hat w ill not j eopar dize healt h st at us, som e accom m odat ions and m odificat ions ar e r equir ed:

1 .

DAI LY MONI TORI NG- XXXXXX’s diabet es m anagem ent r equires t hat he be able t o t ak e fr equent br eak s w hen


t he need ar ises t o a) t r eat low blood sugar s, b) use t he r est r oom , c) t est his glucose levels, and d) adm inist er


insulin . Alt hough XXXXXX’s diabet es m anagem ent has been r elat iv ely st able, t he pr esence of addit ional


aut oim m une diseases put s his fut ur e diabet es m anagem ent and long - t er m healt h at r isk .

2 .

WATER I NTAKE & BATHROOM BREAKS - XXXXXX’s lack of a colon causes him t o use t he r est r oom fr equent ly ,


and he m ust dr ink a lar ge am ount of w at er t hr oughout t he day t o pr ev ent dehy dr at ion .

3 .

LI MI T PHYSI CAL EXERTI ON - His ank y losing spondy lit is causes him day s w it h sev er e back pain, m ak ing


r igor ous act iv it y v er y painful. Task s r equir ing heav y lift ing or hav ing t o sit or st and for a pr olonged per iod of


t im e w it hout br eaks exacer bat e his condit ion and ar e har m ful t o his spine. Class schedules and locat ion of


classr oom s, t im e needed t o change t r av el t o nex t class need t o be ev aluat ed . Ther e m ay be a need for


addit ional accom m odat ions in t he fut ur e, such as m obilit y assist ance, elev at or use, use of lapt op or cell phone


t o allev iat e unnecessar y phy sical t r av el.

4 .

ATTENDANCE - Episodes of sev er e hy pogly cem ia or k et oacidosis, pouchit is infect ions, and sev er e spinal pain


can r esult in XXXXXX’s need for addit ional sick days t o t r eat t he accom pany ing fever , diar r hea, and abdom inal


pain . Teacher s w ill need t o allow for incr eased t im e t o m ak e up schoolw or k or ot her for m s of inst r uct ion if


absent eeism is due t o not ed healt h issues.

5 .

ACCOMODATI ONS - XXXXXX has had a 504 plan in place at school ( K- 12) t o ensur e t hese accom m odat ions


hav e been allow ed. The indiv idualized em ploy m ent plan / indiv idual w r it t en r ehabilit at ion plan, t hat w ill be


dev eloped bet w een VR and XXXXXX w ill need t o specify needed accom m odat ions. While in college, XXXXXX


w ill need t o coor dinat e accom m odat ions ( healt h, lear ning and t est ing) for m ax im ized per for m ance w it h t he


Disabilit y Resour ce Cent er s on cam pus.

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