PHYSICIANS ADA JOB ACCOMMODATION REQUEST DISABILITY VERIFICATION FORM 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the NAME OF PATIENT/EMPLOYEE and the DATE at the top of the form. This information is crucial for identifying the individual requesting accommodations.
3. Proceed to answer the questions regarding the employee's disability. Indicate whether you have examined the employee and are familiar with their medical history, and respond to each question with a 'Yes' or 'No'.
4. In the section about major life activities, check all applicable activities that are affected by the impairment. This helps clarify how the disability impacts daily functions.
5. Next, provide details on any specific functional limitations or restrictions related to essential job functions. Use the chart provided to outline these limitations clearly.
6. Complete the Medical Provider Information section by filling in your name, practice details, and contact information. Ensure your signature and date are included before submission.

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