Attachment 3 "Letter to Medical Provider Requesting Supporting Documentation for Reasonable Accommodation Under the Ada - Sample" - Florida

What Is Attachment 3?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 17, 2011;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Attachment 3 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download Attachment 3 "Letter to Medical Provider Requesting Supporting Documentation for Reasonable Accommodation Under the Ada - Sample" - Florida

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Attachment 3 
FDJJ 1060 – 3 
New 8/17/11 
 
SAMPLE LETTER
to Medical Provider Requesting Supporting Documentation
for Reasonable Accommodation under the ADA
(Use DJJ letterhead paper)
Date:
Doctor’s Name and address
Re: (Employee Name)
Dear Dr.
Your patient, ________________________________, is an employee of the Department of
Juvenile Justice and has requested a reasonable accommodation for their qualifying condition.
In order to satisfy our obligations under the provisions of the Americans with Disability Act, the
Department is requesting additional information to determine what appropriate accommodations
should be provided. A signed Release of Medical Information is attached.
Because the Department is not qualified to interpret medical records, we ask that you do not
send us copies of the employee’s medical records. Instead, we ask that you please read and
reply to the best of your ability, all of the questions on the attached “Certification of Health Care
Provider - ADA” Form.
Thank you for your time and effort in fulfilling this request. If you should have any questions,
please feel free to contact me at _____________________________________
Sincerely,
Attachments
Attachment 3 
FDJJ 1060 – 3 
New 8/17/11 
 
SAMPLE LETTER
to Medical Provider Requesting Supporting Documentation
for Reasonable Accommodation under the ADA
(Use DJJ letterhead paper)
Date:
Doctor’s Name and address
Re: (Employee Name)
Dear Dr.
Your patient, ________________________________, is an employee of the Department of
Juvenile Justice and has requested a reasonable accommodation for their qualifying condition.
In order to satisfy our obligations under the provisions of the Americans with Disability Act, the
Department is requesting additional information to determine what appropriate accommodations
should be provided. A signed Release of Medical Information is attached.
Because the Department is not qualified to interpret medical records, we ask that you do not
send us copies of the employee’s medical records. Instead, we ask that you please read and
reply to the best of your ability, all of the questions on the attached “Certification of Health Care
Provider - ADA” Form.
Thank you for your time and effort in fulfilling this request. If you should have any questions,
please feel free to contact me at _____________________________________
Sincerely,
Attachments