Doctor Letter Template - Free Download
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Doctor Letter Template
Doctor Letter Template
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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 purpose 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 (see
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. Enclosed 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-secondary college courses – if supported. It will be essential 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. Please contact me if you require further information.
Sincerely,
XXXXXXXXX, M.D.
Etc.
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