Request for Accommodations under the Americans with Disabilities Act (ADA) - Test Accommodation Application Form

Sep 26, 2026

Uploaded by Patrick

ADA test accommodation application form used by AHIMA to collect applicant identity details, the specific examinations requested (e.g., CCA/CCS/RHIA/RHIT/CHPS), disability type, diagnosis timing, and requested accommodation options such as separate testing rooms, reader support, extended time, and screen magnifier/zoom technology. It also requires an attached qualified professional’s documentation describing diagnosis, functional limitations, diagnostic criteria/tests and results, relevant records, and recommendations explaining how accommodations reduce impact.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

AccessFree to download

Part I: Request for Accommodations under the ADA

Applicant information and requested accommodations

Part II: Information from a Qualified Health Professional

Required documentation and report contents

PART I Request for Accommodations under the Americans with Disabilities Act (ADA) 1. First Name: MI: Last Name: 2. Address: City: State: Zip Code: Country: AHIMA ID: 3. For which of the following exams are you requesting accommodations? CCA CCS CCS-P RHIA RHIT CHPS CHDA CDIP 4. Nature of your disability: Hearing Learning Visual Psychiatric Physical Other, please specify 5. How long ago was your disability diagnosed? Less than 1 year 1–2 years 2–5 years Over 5 years 6. In order to fully document your need for accommodations, please include a brief personal statement describing your disability and its impact on your daily life and educational functioning. 7. Have you previously received accommodations in any educational or testing situation? Yes No If yes, please describe the accommodations received. 8. Which of the following accommodations are you requesting? Separate testing room Reader Extended testing time Other, please specify Screen magnifier/zoom technology I certify that the information provided above is true and accurate. Signature: Date: PART II Information to be provided by a qualified health professional, and attached to Part I of the ADA application. Documentation of disability assists AHIMA in determining reasonable accommodations under the Americans with Disabilities Act, which are determined on a case-by-case basis. If the submitted documentation is incomplete or does not support the request, the applicant will be asked to provide additional documentation. The cost of obtaining all documentation is borne by the applicant. The documentation submitted should be as comprehensive as possible in order to allow AHIMA to make an informed decision on the accommodation request and to avoid delays in the decision-making process. Documentation, along with the AHIMA Test Accommodation Request Form should be submitted to AHIMA early enough to allow sufficient time to review the request and implement reasonable accommodations and/or services within registration deadlines. Documentation must be provided by a licensed or otherwise properly credentialed professional who has undergone appropriate and comprehensive training, has relevant experience, and has no familial relationship with the individual being evaluated. The individual making the diagnosis must be qualified to do so (for example, an orthopedic limitation might be documented by a physician, but not a licensed psychologist) . Documentation should be typed or printed on official letterhead with the name, title, professional credentials, address, phone number, and signature of the evaluator, as well as the date of the report. The documentation should be current. Because the provision of reasonable accommodations is based on assessment of the current impact of the applicant’s disability on the testing activity, it is in the individual’s best interest to provide recent documentation. As the manifestations of a disability may vary over time and in different settings, in most cases an evaluation should have been conducted within the past three years. Certain conditions such as some physical and psychiatric conditions are subject to change and should be updated for current functioning. Please scan the completed application and [supporting documentation to :](supporting documentation to : ada@ahima.org)[ ](supporting documentation to : ada@ahima.org)[ada@ahima.org](supporting documentation to : ada@ahima.org) PART II (continued) To support a request for test accommodations, please submit the following materials: 1. A completed AHIMA Test Accommodation Request Form. 2. A detailed, comprehensive written report from your treating professional describing your disability and its impact on your daily functioning. The report should also explain the need for the requested accommodations relative to your impairment. The report and accompanying documentation sho

FAQs

What information must be provided in Part I of the ADA application?

Part I collects applicant identity details, the exams for which accommodations are requested, disability nature, diagnosis timing, and a personal statement about disability impact. It also lists requested accommodations such as separate testing room, reader, extended testing time, and screen magnifier/zoom technology, and includes certification with signature and date.

Who must provide the documentation for Part II?

Documentation must be provided by a licensed or otherwise properly credentialed health professional with appropriate training and relevant experience, with no familial relationship to the individual evaluated. The diagnosing individual must be qualified for the specific condition.

What must the professional report include to support test accommodations?

The report should provide a specific recognized diagnosis with DSM diagnostic codes or other recognized formulation, functional limitations and impacted major life activity, diagnostic criteria and tests with dates and detailed interpretation, standard scores using adult age-based norms, and relevant educational/developmental/medical history and records. It must also recommend specific accommodations or assistive devices and explain how they reduce the identified functional limitations.

Sep 26, 2026

Uploaded by Patrick