RE John (XXXXXX) XXXXXXX, Age 18, DOB XXXX1986

Sample Letter to Document Disability

From Primary Care Physician

Date

TO:

To Vocational Rehabilitation

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.

XXXXXX XXXXXX

Chronic Health Issues

1. TYPE ONE DIABETES, ICD-9 CODE: 250.01, Diagnosed: 1998; age 12 years

Health Impact to XXXXXX – He requires daily insulin, strict dietary management, and daily/hourly

monitoring and management of blood sugar levels. He has been hospitalized several times, either for

severe hypoglycemia or ketoacidosis.

2. ULCERATIVE COLITIS, ICD-9 CODE: 556.9, Diagnosed: Diagnosed 2000; age 14 years

XXXXXX required surgery for this. He had a colectomy.

Health Impact to XXXXXX – Although he technically no longer has ulcerative colitis due to the absence of a

colon, he continues to suffer from acute episodes of pouchitis. Symptoms, including steadily increasing

stool frequency that may be accompanied by incontinence, bleeding, fever and/or feeling of urgency. Most

cases can be treated with a short course of antibiotics. Additionally, absence of a colon causes problems

with nutritional absorption and is associated with XXXXXX’s below-average weight.

3. ANKYLOSING SPONDYLITIS, ICD-9 CODE: 720.0, Diagnosed: 2000; age 14 years

Health Impact to XXXXXX – his degenerative spinal arthritis that causes episodes of severe pain and

limitations on his physical capabilities, requiring medication and a physical therapy regime for

management.

ACCOMODATIONS REQUIRED – SCHOOL /EMPLOYMENT TRAINING/PREPARATION

In order to maximize XXXXXX’s performance level that will not jeopardize health status, some accommodations and

modifications are required:

1. DAILY MONITORING- XXXXXX’s diabetes management requires that he be able to take frequent breaks when

the need arises to a) treat low blood sugars, b) use the restroom, c) test his glucose levels, and d) administer

insulin. Although XXXXXX’s diabetes management has been relatively stable, the presence of additional

autoimmune diseases puts his future diabetes management and long-term health at risk.

2. WATER INTAKE & BATHROOM BREAKS - XXXXXX’s lack of a colon causes him to use the restroom frequently,

and he must drink a large amount of water throughout the day to prevent dehydration.

3. LIMIT PHYSICAL EXERTION - His ankylosing spondylitis causes him days with severe back pain, making

rigorous activity very painful. Tasks requiring heavy lifting or having to sit or stand for a prolonged period of

time without breaks exacerbate his condition and are harmful to his spine. Class schedules and location of

classrooms, time needed to change travel to next class need to be evaluated. There may be a need for

additional accommodations in the future, such as mobility assistance, elevator use, use of laptop or cell phone

to alleviate unnecessary physical travel.

4. ATTENDANCE - Episodes of severe hypoglycemia or ketoacidosis, pouchitis infections, and severe spinal pain

can result in XXXXXX’s need for additional sick days to treat the accompanying fever, diarrhea, and abdominal

pain. Teachers will need to allow for increased time to make up schoolwork or other forms of instruction if

absenteeism is due to noted health issues.

5. ACCOMODATIONS - XXXXXX has had a 504 plan in place at school (K-12) to ensure these accommodations

have been allowed. The individualized employment plan / individual written rehabilitation plan, that will be

developed between VR and XXXXXX will need to specify needed accommodations. While in college, XXXXXX

will need to coordinate accommodations (health, learning and testing) for maximized performance with the

Disability Resource Centers on campus.