Medical Certification

This is a Certification of need for reasonable accommodation or structural modification. It is to be completed by a qualified medical provider.

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Reasonable_accommodation_certification_by_medical_provider.pdfpdf document

 

CERTIFICATION OF NEED FOR REASONABLE
ACCOMMODATION or STRUCTURAL MODIFICATION

Dear (name of medical professional)

(name of Applicant/Resident) has given the XYZ Company permission to contact you (see attached) to verify that he/she has a disability within the meaning of the definition provided below, and as a direct result of his/her disability, needs a change in a rule, policy, procedure, or service, a physical change in an apartment or other facility or an accessible apartment.

Please do not send us medical records or disclose what type of disability he/she has. Please return this form to: using the stamped self-addressed envelope provided. Thank you.

Please answer the following questions:

  1. In my opinion, the Applicant or Resident has a disability as defined by one of the categories below:

[ ] yes [ ] No [ ] No Knowledge

  1. Has a physical or mental impairment that substantially limits one or more major life activities;
  2. Has a record of having such an impairment;
  3. Is regarded as having such impairment.

Note: For the purpose of this form, the term physical or mental impairment includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech, and hearing impairments, cerebral palsy, autism, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, Human Immunodeficiency Virus infection, mental retardation, emotional illness, and drug addiction (not current illegal use of a controlled substance). The term major life activity includes, but is not limited to walking, seeing, hearing, speaking, breathing, learning, and working.

  1. The applicant/resident has requested the following accommodation and/or physical modification to a unit or other facility. ________________________________
  2. In my opinion the applicant/resident needs the above accommodation/modification as a direct result of his/her disability
  3. in order for him/her to apply for and/or reside in a Public Housing unit.

    4. [ ] Yes [ ] No [ ] No Knowledge

  4. In my opinion, as a direct result of the applicant/tenant’s disability he/she needs additional physical modifications to the
  5. unit or common area or reasonable accommodations to the rules and policies of the housing development or auxiliary
  6. aides or services be in order for the Applicant or Resident to apply for or reside in a Public Housing unit.

[ ] Yes [ ] No [ ] No Knowledge

If yes, please describe:

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________

Date Signature

____________________________________

Title of Medical Professional

____________________________________

Affiliation

____________________________________

Address

____________________________________

Phone

 

PENALTIES FOR MISUSING THIS CONSENT

Title 18, Section 1001 of the U.S. Code states that a person who knowingly and willingly makes false and fraudulent statements to any department of the United States Government, HUD, the PHA, and any owner (or any employee of HUD, the PHA, or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information.

Use of the information collected based on this verification form is restricted to the purposes cited above.

If you have any questions about filling out this form, please call the 504 Coordinator, Telephone: (TDD):

The Fair Housing Act prohibits discrimination in housing based on color, race, religion, national origin, sex, family status, or disability.