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The patient authorizes a medical provider to disclose relevant information about a medical condition to the employer solely to evaluate an ADA reasonable accommodation request. The form also allows direct communication with treating providers, explains patient refusal implications, and requests medical and functional limitation details, onset, current status, major life activity impact, job performance interference, and recommended accommodations. 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This letter further authorizes OEO to speak tomy treating physician or health care provider directly in regards to any questions they may have with respect to my condition that relates to the performance of the essential functions of my job and any accommodations which may be necessary.  \nI understand the requested data is for the above-mentioned purposes and I may refuse to provide the requested medical information. However, I also understand that if I refuse to provide the information, my employer may refuse to provide reasonable accommodation.  \nPatient Signature/Tufts University Employee Date  \nOffice of Equal Opportunity  \nAttention Medical Practitioner:  \nThe staff/faculty member named below has indicated they have a disability and will require reasonable accommodation(s) for the purposes of employment or to participate in a program or activity at Tufts University. In order for Tufts to proceed, we require additional information about the employee’s medical condition. We are enclosing with this a medical form (Accommodation Authorization for Release of Medical Information) so the employee is fully informed of what we are asking and can approve the release of the information needed.  \nThe American with Disabilities Act (ADA) requires employers to provide reasonable accommodations to employees who are disabled, i.e. , have a medical condition that substantially limits a major life function. We are requesting the following information to determine if the employee is covered under the ADA, and if so, an explanation of the nature of the condition specific to which major life activities the condition limits. In addition, please advise us regarding what accommodations you believe the employee needs in order to perform their job duties and responsibilities. It may be helpful for you to ask the employee's about their job responsibilities and/or job description , and have them make known to you any accommodations they are seeking.  \nPlease return the completed signed forms or send them by fax (please adhere to HIPAA regulations and call before faxing) to Tufts University, Office of Equal Opportunity, at the following address/fax number:  \nTufts University  \nOffice of Equal Opportunity  \n196 Boston Avenue, Suite 4000B Medford, MA 02155  \nFax: 617.627.3075 Phone: 617.627.3298  \nIf you have any questions or concerns about this form, please contact the Tufts [Accommodations Team at ](Accommodations Team at Accommodations.OEO@tufts.edu)[Accommodations.OEO@tufts.edu](Accommodations Team at Accommodations.OEO@tufts.edu).  \n196 Boston Avenue, 4th floor, Medford, MA 02155 |Tel: 617 .627.3298| FAX: 617 .627.3150|WEB: [oeo.tufts.edu](oeo.tufts.edu)  \n1. Patient Name:    \n2. Nature of patient's condition(s):    \n\n| 3. Date of onset of condition(s):  \u003Cbr>4. Current status of condition(s): (e.g. Active, Progressing, Controlled, In Remission):   |\n| --- |\n| 5. How long is this condition(s) likely to exist (be as specific as possible: e.g., lifetime, one year; six months; one month) :  |\n| 6. Does the condition(s) affect a major life activity? Yes [ ] No [ ]\u003Cbr>If yes, what major life activity(s) is/are affected?\u003Cbr>[ ] Caring for Self [ ] Walking [ ] Hearing [ ] Standing\u003Cbr>[ ] Seeing [ ] Sleeping [ ] Reaching [ ] Speaking\u003Cbr>[ ] Breathing [ ] Toileting [ ] Learning [ ] Working\u003Cbr>[ ] Lifting [ ] Reproduction [ ] Concentrating\u003Cbr>[ ] Performing Ma","cbCaigPF1z6iDgKt","https://ap.wps.com/l/cbCaigPF1z6iDgKt","pdf",411735,"English","# Accommodation Authorization for Release of Medical Information\n## Patient Authorization and Consent\n## Medical Practitioner Request and Instructions\n## Medical Information Fields\n## Provider Signature and Return Information","[{\"question\":\"What does the patient authorize the medical provider to disclose?\",\"answer\":\"The patient authorizes the medical provider to disclose requested information about the medical condition to Tufts University’s Office of Equal Opportunity for evaluating an ADA reasonable accommodation request.\"},{\"question\":\"How does refusal to provide medical information affect accommodation?\",\"answer\":\"The patient may refuse to provide the requested medical information, but the employer may refuse to provide reasonable accommodation if the information is not provided.\"},{\"question\":\"What medical details are requested on the form?\",\"answer\":\"The form requests patient name, nature of the condition(s), date of onset, current status, expected duration, whether major life activities are affected (with selectable categories), and how limitations interfere with job performance, job functions, and recommended accommodations.\"}]","Accommodation Authorization for Release of Medical Information - Employee Medical Release Letter Form | PDF",1789538112]