Healthcare Accommodation Meeting

HEALTHCARE ACCOMMODATION MEETING

Patient Information

Date of Birth:    Gender:

Insurance Information

Medical History (Relevant)

Meeting Details

Meeting Date:    Meeting Time:

Accommodation Request

Documentation Provided at Meeting: Yes    If yes, specify:

Accommodation Options Considered (check all that apply):

Modified schedule or timing    Physical modification of space    Assistive equipment/devices

Job restructuring or role adjustment    Leave or scheduling of appointments    Other (describe below)

Assessment and Determination

Effective Date:    Anticipated Duration:

Determination: Approved    Approved with Modification    Denied

Confidentiality and Authorization

The facility will limit disclosure of medical information to personnel with a need to know for the purpose of implementing or evaluating accommodations. Information retained in medical records will be handled in accordance with applicable privacy laws.

I authorize limited release of medical information necessary to evaluate and implement the accommodation described above to the following individuals or departments:

Authorization Expiration Date:

I understand that I may withdraw this authorization in writing at any time, but that withdrawal will not affect actions taken in reliance on this authorization prior to receipt of the revocation.

Patient Certification

By signing below, I certify that the information I have provided in this meeting record is true and complete to the best of my knowledge. I understand that the facility's agreement to provide accommodations is contingent on the accuracy of the information provided and any medical documentation submitted to support the request.

I acknowledge that I have been offered the opportunity to ask questions about the accommodation process and that I may request additional review or appeal of a denial in accordance with facility procedures.

Sign Now