Fill and Sign the Essential Job Functions under the Adanolo Form

RESPONSE FORM FOR ADA REQUEST FROM MEDICAL PRACTITIONER The employee is is not able to perform the essential functions of his/her position. If not able, the essential functions that physically or mentally cannot be performed are: Are you aware of any measures the employee or the employer can take to enable the employee to perform the described essential functions? Yes No If yes, explain: The employee is is not physically or mentally able to perform the marginal functions of the job. If not able, what marginal functions cannot be performed? Are you aware of any measures the employee or the employer can take to enable the employee to perform the described marginal functions? Yes No Please describe those accommodations: The employee’s performance of the essential job duties would would not constitute a direct threat to the employee or to others. If a direct threat would exist:1) specifically describe the nature of the threat, its severity, the probability of it occurring and when, and its duration: 2) describe any accommodations that might alleviate, in whole or in part, the threat: I would would not recommend further medical evaluation as to the employee’s present abilities to perform the described job functions and whether he/she would represent a direct threat by such performance. The following tests and/or evaluations were conducted: Name of Health Care Provider: Signature: Date: CERTIFICATION OF PHYSICIAN OR PRACTITIONER Return completed form in a sealed envelope, marked personal and confidential, to: EMPLOYEE/PATIENT INFORMATION AND INFORMED CONSENT FOR DISCLOSURE OF HEALTH CARE I NFORMATION Employee's Name: Social Security Number: Employee's Address: City, State, Zip:Telephone Number: Patient's Name: Patient's Age: Relationship to Employee: HIPAA-COMPLIANT AUTHORIZATION TO RELEASE INFORMATION: By completing this document, I demonstrate my informed consent and authorization to allow the physician or practitioner identified on this form to release an d disclose to _____________________________________________ such health care records and information concerning my current medical condition as is necessary to support my requ est for a leave of absence and/or any additional benefits the employer may provide. Th is authorization is made per my request. This authorization shall be valid for two (2) years from the dat e shown below, unless revoked by me in writing at an earlier date. Although I understand that I may revoke this authorization in writing at any time, I also understand that any such revocation will not app ly to any information that has already been released in reliance on this authorization, and that any re vocation may have an adverse effect on the receipt of employer-provided benefits. I understand that my medi cal treatment is not conditioned upon me providing this authorization. I understand that if thi s authorization is for the release of psychotherapy notes I will complete a separate authorization for any other health information. I understand that information disclosed by the physician or practitioner to the emp loyer may be subject to redisclosure and not protected by the Health Insurance Portability and Account ability Act of 1996 (“HIPAA”). Employee Signature: __________________________________ ____________ Date: Alternatively, signature of Personal Representative and stateme nt of authority to act on behalf of individual: ______________________________ _____________________ _________ Date: IF PATIENT IS ADULT FAMILY MEMBER OF EMPLOYEE: Patient Signature: Date: IF PATIENT IS MINOR CHILD: Signature of Parent or Guardian:Date: