www.hrtw Sample Letter to Document Disability From Primary Care Physician
To Vocational Rehabilitation
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 purpo 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 (e 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. Enclod 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-condary college cours – if supported. It will be esntial 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. Plea contact me if you require further information.
Sincerely,
XXXXXXXXX, M.D.
Etc.
XXXXXX XXXXXX Chronic Health Issues
1. TYPE ONE DIABETES, ICD-9 CODE: 250.01, Diagnod: 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 veral times, either for
vere hypoglycemia or ketoacidosis.
2. ULCERATIVE COLITIS, ICD-9 CODE: 556.9, Diagnod: Diagnod 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 abnce of a colon, he continues to suffer from acute episodes of pouchitis. Symptoms, including ste
adily increasing
stool frequency that may be accompanied by incontinence, bleeding, fever and/or feeling of urgency. Most cas can be treated with a short cour of antibiotics. Additionally, abnce of a colon caus problems
with nutritional absorption and is associated with XXXXXX’s below-average weight.
3. ANKYLOSING SPONDYLITIS, ICD-9 CODE: 720.0, Diagnod: 2000; age 14 years
Health Impact to XXXXXX – his degenerative spinal arthritis that caus episodes of vere 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 aris to a) treat low blood sugars, b) u the restroom, c) test his gluco levels, and d) administer insulin. Although XXXXXX’s diabetes management has been relatively stable, the prence of additional
autoimmune dias puts his future diabetes management and long-term health at risk.
2. WATER INTAKE & BATHROOM BREAKS - XXXXXX’s lack of a colon caus him to u 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 caus him days with vere 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 u, u of laptop or cell phone to alleviate unnecessary physical travel.
4. ATTENDANCE - Episodes of vere hypoglycemia or ketoacidosis, pouchitis infections, and vere 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 incread time to make up schoolwork or other forms of instruction if abnteeism is due to noted health issues.
5. ACCOMODATIONS - XXXXXX has had a 504 plan in place at school (K-12) to ensure the 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.
