You may use this form to ask your provider or doctor for information to confirm or clarify your medical conditions. You can use this information to support your request for a reasonable accommodation or modification.
English:
- Form: Request for Medical Information from Your Provider (accessible PDF)
- Fillable English form letter (Word document)
Spanish:
- Formulario: Cómo solicitar información médica de su proveedor (accessible PDF)
- Fillable Spanish form letter (Word document)
HMoob:
- Daim Ntawv: Kev Thov rau Cov Ntaub Ntawv Kho Mob los ntawm Koj Tus Kws Kho Mob (accessible PDF)
- Fillable HMoob form letter (Word document)
Updated: August 2026