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SampleLettertoDocumentDisability

FromPrimaryCarePhysician

ToVocationalRehabilitation

Date

TO:NAMEOFVRCOUNSELOR

OfficeofRehabilitationServices

ADDRESS

CITY,STATE

FROM:DOCTOR’sNAME(itsbetterifthisisonthephysician’sletterhead)

RE:John(XXXXXX)XXXXXXX,Age18,DOBXX/XX/1986

Phone:XXX-XXX-XXXX

GraduateofXXXXXXHighSchoolasofJune9,2004

DearNAMEOFVRCOUNSELOR,

Thepurpoofthisletteristodocumentsignificantchronichealthconditionsthatimpairactivitiesofdailylivingfor

XXXXXXX–eenhisprimarycarephysicianfor18years.

XXXXXX’shealthissuesandtheireffectonschoolandpotentialemploymentdomeetthedefinitionofdisabilityby

Utah’sVocationalRehabilitationcriteria[Title53AChapter24,102(3)]andADAandSection504requirements(e

factsheetonlastpage).

SIGNIFICANTHEALTHIMPAIRMENTS

•EndocrineSystem-TYPEONEDIABETES

•DigestiveSystem-ULCERATIVECOLITIS

•ImmuneSystem-ANKYLOSINGSPONDYLITIS

CONFIDENTIALITYSAFEGUARDS-IncompliancewithHIPAAconfidentialitymandatespermissionforthispersonal

healthinformationhasbeenobtainedbythepatient,andassuchthislettershouldbetreatedashighlyconfidential

recordsandnotsharedwithoutthepatient’spermission.

edarerelevantreportsandfindings

ofrecentandpasthealthrelatedmedicaltesting.

TRAININGFOREMPLOYMENT&IMPORTANTOFHEALTHCAREBENEFITS

ItisimportanttoconsiderwhatXXXXXXcoulddotomeethispotential,liveindependently,andremainashealthy

isaverybrightyoungmanwhohasdisplayednumeroustalentsinmusic,art,writing,

literature,andscience.

Givenhiducationalperformance,intellectualabilitiesandaspirations,hecertainlyhasthepotentialtodowellin

competitiveemploymentthroughpost-condarycollegecours–beesntialthatcareer

developmentbeaimedatstable;well-payingjobsthatoffercomprehensivebenefitstoassuremaintainhealth

statusandfinancialindependence.

Insum,IbelievethatofferingXXXXXXfinancialandtechnologysupportthroughtheOfficeofRehabilitative

Serviceswouldensurenotonlyemployabilitybutalsowouldsupportallimportantaspectsofindependentliving

contactmeifyourequirefurtherinformation.

Sincerely,

XXXXXXXXX,M.D.

Etc.

XXXXXXXXXXXXChronicHealthIssues

EDIABETES,ICD-9CODE:250.01,Diagnod:1998;age12years

HealthImpacttoXXXXXX–Herequiresdailyinsulin,strictdietarymanagement,anddaily/hourly

eenhospitalizedveraltimes,eitherfor

verehypoglycemiaorketoacidosis.

TIVECOLITIS,ICD-9CODE:556.9,Diagnod:Diagnod2000;age14years

colectomy.

HealthImpacttoXXXXXX–Althoughhetechnicallynolongerhasulcerativecolitisduetotheabnceofa

colon,ms,includingsteadilyincreasing

stoolfrequencythatmaybeaccompaniedbyincontinence,bleeding,feverand/

onally,abnceofacoloncausproblems

withnutritionalabsorptionandisassociatedwithXXXXXX’sbelow-averageweight.

SINGSPONDYLITIS,ICD-9CODE:720.0,Diagnod:2000;age14years

HealthImpacttoXXXXXX–hisdegenerativespinalarthritisthatcaupisodesofverepainand

limitationsonhisphysicalcapabilities,requiringmedicationandaphysicaltherapyregimefor

management.

ACCOMODATIONSREQUIRED–SCHOOL/EMPLOYMENTTRAINING/PREPARATION

InordertomaximizeXXXXXX’sperformancelevelthatwillnotjeopardizehealthstatus,someaccommodationsand

modificationsarerequired:

ONITORING-XXXXXX’sdiabetesmanagementrequiresthathebeabletotakefrequentbreakswhen

theneedaristoa)treatlowbloodsugars,b)utherestroom,c)testhisglucolevels,andd)administer

ghXXXXXX’sdiabetesmanagementhasbeenrelativelystable,theprenceofadditional

autoimmunediasputshisfuturediabetesmanagementandlong-termhealthatrisk.

NTAKE&BATHROOMBREAKS-XXXXXX’slackofacoloncaushimtoutherestroomfrequently,

andhemustdrinkalargeamountofwaterthroughoutthedaytopreventdehydration.

HYSICALEXERTION-Hisankylosingspondylitiscaushimdayswithverebackpain,making

equiringheavyliftingorhavingtositorstandforaprolongedperiodof

chedulesandlocationof

classrooms,aybeaneedfor

additionalaccommodationsinthefuture,suchasmobilityassistance,elevatoru,uoflaptoporcellphone

toalleviateunnecessaryphysicaltravel.

ANCE-Episodesofverehypoglycemiaorketoacidosis,pouchitisinfections,andverespinalpain

canresultinXXXXXX’sneedforadditionalsickdaystotreattheaccompanyingfever,diarrhea,andabdominal

rswillneedtoallowforincreadtimetomakeupschoolworkorotherformsofinstructionif

abnteeismisduetonotedhealthissues.

DATIONS-XXXXXXhashada504planinplaceatschool(K-12)toensuretheaccommodations

ividualizedemploymentplan/individualwrittenrehabilitationplan,thatwillbe

dncollege,XXXXXX

willneedtocoordinateaccommodations(health,learningandtesting)formaximizedperformancewiththe

DisabilityResourceCentersoncampus.