ADA Reasonable Accommodation Letter and Questionnaire to Healthcare Provider
(with HIPAA Authorization)

Summary

This template is an ADA reasonable accommodation letter and questionnaire to healthcare provider, with HIPAA authorization, for employers to use when requesting the assistance of doctors or other healthcare providers to satisfy their obligation under the Americans with Disabilities Act of assessing an employee's ability to perform the essential functions of the job. This template includes practical guidance, drafting notes, and alternate clauses. This template is intended for private employers. It is based on federal law and does not address all potential state law distinctions; thus, you should check any relevant state and local laws. Typically, the employer request includes a transmittal letter, questionnaire, and employee authorization to use/disclose personal health information that satisfies the Health Insurance Portability and Accountability Act (HIPAA) and applicable state law. For information on healthcare provider certifications, see Medical and Fitness for Duty Certifications and Permissible Disability-Related Inquiries, Medical Exams, and Certifications: Key Considerations. For templates related to the reasonable accommodation of disabilities, see Disability and Reasonable Accommodation Policy, Disability Accommodations Policy (with Acknowledgment), Disability Accommodation Request (ADA), and Disability Accommodation Request Resolution (ADA). For information on reasonable accommodations, see Disability and Reasonable Accommodation Policies: Key Drafting Tips and Americans with Disabilities Act: Guidance for Employers. For information on HIPAA requirements, see Confidential Medical Information in the Employee Leaves and Disability Context (Including Dobbs Considerations), HIPAA Privacy, Security, Breach Notification, and Other Administrative Simplification Rules, and Brightmine HR & Compliance Center Employment Law Guide 2154. For HIPAA authorization templates, see HIPAA Authorization for PHI Use or Disclosure.