Note for your health care provider
A printable from Disability Accommodation at Work. Fill it in by hand. Nothing you write is collected by this website.
Note for your health care provider
Please write a short note on your letterhead that says:
- My patient, ______________, has a health condition that limits: ______________ (for example, lifting, standing, concentrating, typing)
- To do their job, they need this change: ______________
- Starting ______________ and lasting about ______________ (or "ongoing")
- Your name, title, signature, date and phone number
The note does not need to name the diagnosis or include medical records.
From Disability Accommodation at Work. Facts checked October 21, 2026. Free information, not legal or medical advice.