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The health care provider is asked whether the patient has a physical or mental condition that substantially limits a major life activity, whether an assistance animal alleviates symptoms or effects, and whether any fee or compensation was received solely for the written finding. 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In connection with that application, I am requesting that you, my health care provider, complete this form regarding my disability.  \nPatient/Client/Requester’s Signature Date  \nTO BE COMPLETED BY HEALTH CARE PROVIDER/ LICENSEE  \n1. Does your patient/client identified above have a physical or mental condition that substantially limits a major life activity? ☐ Yes ☐ No  \n2. Does or would an assistance animal alleviate one or more of the symptoms or effects of the condition?  \n☐ Yes ☐ No  \nIf yes, what particular assistance does the animal provide to your patient/client?  \n3. As the health care provider/licensee listed below, have you received a separate fee, additional fee, or other form of compensation solely in exchange for making this written finding? ☐ Yes ☐ No  \n4. This letter was issued on   . It will expire after 12 months or at the expiration of the term of your patient/client’s rental agreement, whichever is greater.1  \nBy signing below, you certify you: 1) have had a relationship with the patient/client for at least thirty (30) days; 2) have met with the patient/client in person or by telemedicine, 3) are sufficiently familiar with the patient/client and their disability, prior to writing the finding, to make the finding; and 4) are legally and professionally qualified to make the finding.  \nHealth Care Provider/Licensee’s Name (printed):   Signature:    \nDate:    \nThis document may contain privileged and confidential information and/or protected health information intended solely for use by the recipient housing provider. Please exercise care to avoid dissemination.  \n1 Unless you as the health care provider/licensee provide a shorter expiration date.  \nReferences: Iowa Code sections 216. 8B and 216. 8C  \nResources: [https://icrc.iowa.gov/](https://icrc.iowa.gov/), 515-281-4121, 1-800-457-4416","cbCaieROF4wnZn5g","https://ap.wps.com/l/cbCaieROF4wnZn5g","pdf",129341,"English","# Patient/Client/Requester Information\n## Health Care Provider/Licensee Questions\n## Certification, Signature, and Expiration","[{\"question\":\"What is the purpose of this assistance animal form?\",\"answer\":\"It supports a request to a housing provider to allow an assistance animal as a reasonable accommodation for a disability, with the health care provider completing the disability-related finding.\"},{\"question\":\"What questions does the health care provider/ licensee must answer?\",\"answer\":\"They must indicate whether the patient has a physical or mental condition that substantially limits a major life activity, and whether an assistance animal alleviates symptoms or effects, and whether any separate or additional compensation was received solely for making the written finding.\"},{\"question\":\"How long is the provider’s written finding valid?\",\"answer\":\"It expires after 12 months or at the expiration of the patient/client’s rental agreement term, whichever is greater.\"}]","Assistance Animal - Health Care Provider/Licensee Form - Draft 2.0 | PDF"]