Medical Seizure Letter

MEDICAL SEIZURE LETTER

Patient Name:    Date of Birth:

WHEREAS

WHEREAS, the undersigned physician has examined and treated the above-named patient and has determined that the patient has a diagnosed seizure disorder that may periodically impair awareness, motor control, or conscious responsiveness; and

WHEREAS, the patient requires documentation for the purpose of informing relevant third parties and establishing accommodations, emergency response protocols, and temporary activity restrictions; and

WHEREAS, the physician and patient acknowledge that limited disclosure of medical information and a written plan may be necessary to ensure safety and to permit reasonable accommodations by an employer, educational institution, or other relevant entity.

PHYSICIAN / PROVIDER INFORMATION

MEDICAL FINDINGS

Summary of diagnosis and clinical findings (including seizure type, frequency, relevant comorbidities and current medications):

Date of most recent seizure:

SCOPE OF SERVICES AND RECOMMENDED ACCOMMODATIONS

The physician provides the following recommendations to manage risk, permit reasonable accommodations, and document necessary restrictions. These recommendations are medically necessary and based on current clinical assessment:

PERMISSIONS FOR LIMITED DISCLOSURE

The patient may authorize limited disclosure of the foregoing medical information to relevant third parties when necessary to effectuate accommodations or to ensure safety. Consent to disclose is required in writing for parties other than those specifically designated below.

  I authorize limited disclosure to the employer or educational institution named below for the purpose of accommodations.

PAYMENT TERMS (IF APPLICABLE)

The patient agrees to pay for the preparation of this letter and any associated clinical services as set forth below. If no fee is charged, indicate "No fee".

TERM AND TERMINATION

Effective:    Term expires (if applicable):

CONFIDENTIALITY

All medical information disclosed in this letter is confidential and protected by applicable medical privacy laws. The recipient may use the information only to provide accommodations, to implement emergency response procedures, or as otherwise required by law. Any further disclosure requires additional written authorization from the patient.

GOVERNING LAW

This letter shall be governed by and construed in accordance with the laws of the state where the issuing physician maintains a principal place of practice, without regard to conflict of laws principles.

ENTIRE AGREEMENT

This document constitutes the complete and exclusive statement of the medical recommendations, authorizations, and terms described herein. Any modifications must be made in writing and signed by both the patient and the physician.

EMERGENCY CONTACT

ACKNOWLEDGMENT

By signing below, the parties acknowledge that the information contained in this letter is accurate to the best of the physician's knowledge at the time of issuance and that the patient consents to the limited disclosures and terms described herein. The patient understands that medical conditions can change and that the physician may amend or revoke recommendations based on clinical changes.

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