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Medical Disability Form

Medical Disability Form


The medical disability form is used by person with a disability individuals to receive support from certain medical facilities for diagnosis and treatment. It is necessary that such a form has all the parameters with which the individual is to be assessed. It is important that there is sufficient space provided for the medical examiner to put in his comments with regards to the assessment.

Medical Disability Template
Medical Disability Template
Medical Disability Template
Medical Disability Template

You can Download the Medical Disability Form Template, customize it according to your needs, and Print it. Medical Disability Form Template is either in MS Word or Editable PDF.

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Patient Information:

The form collects basic information about the patient, including name, date of birth, and also contact details.

Healthcare Provider Information:

There’s a section for the healthcare provider’s name, contact information, and also license number.

Authorization for Release of Information:

The patient typically signs a section authorizing the healthcare provider to release their medical information to the requesting entity (e.g., employer, insurance company).

Diagnosis Information:

A key feature is a section for the healthcare provider to outline the patient’s medical diagnosis.

Functional Limitations:

The form may ask the healthcare provider to detail any functional limitations caused by the disability. This could include limitations related to mobility, strength, stamina, hearing, vision, or cognitive function.

Restrictions or Accommodations:

Some forms may have a section for specifying any restrictions or reasonable accommodations that may be also helpful for the patient in the workplace or other settings.


Standardized Format:

The template ensures a consistent format for collecting information from healthcare providers, streamlining the verification process for employers, insurance companies, or other institutions.

Privacy Protection:

By requiring patient authorization, the form helps to protect the privacy of their medical information.

Verification of Disability:

The form provides a mechanism for institutions to obtain verification of a patient’s disability from a qualified healthcare professional.

Accommodation Support:

The information gathered through the form can be also used to determine appropriate accommodations for the patient, promoting equal opportunities and participation.

Important Disclaimer: These templates are for informational purposes only. They are not a substitute for legal advice. Before using any template, consult with an attorney to ensure it meets your specific needs. EditableForms.com is not a law firm and cannot accept legal requests.