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Page 2 of 6 PUBLIC HOUSING AUTHORITY VERIFICATION OF DISABILITY |
Name: ______ Date:______________________ Address:_______________________ ______________________________ Dear Resident/Applicant: You have indicated that you, or a member of your household, need a reasonable accommodation because of a disability in connection with a Public Housing Authority residence, facility, program or service. A physician, licensed health care professional, or a professional representing a social service agency or disability agency or clinic may verify this information. Please take or mail this form, the attached Authorization for Release of Information and the enclosed stamped, pre-addressed envelope to your health care provider or other appropriate individual, clinic or agency. The Public Housing Authority will use this information to evaluate your request for a reasonable accommodation. The Public Housing Authority will keep this information confidential. If you choose not to authorize the release of this information, we may not be able to consider your reasonable accommodation request(s). MODIFICATION/ACCOMMODATION REQUESTED: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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