Sample Doctor’s Note and Demand Letter - (to Accompany Disability Laws Fact Sheet)

Aug 30, 2026

This package provides two customizable templates intended to support a tenant’s request for reasonable accommodation under federal and California fair housing and employment laws. The doctor’s note format documents a patient’s disabling medical condition and explains how drifting tobacco smoke interferes with breathing and worsens health. The demand letter template cites key statutes and case law, describes recurring secondhand smoke exposure with an optional log, requests specific non-smoking accommodations, and sets a written response deadline while noting potential liability for denial.

LanguageEnglish

CategoryLetters

FormatDOC

Pages3

Reading Time1 min

AccessFree to download

Doctor’s Note

Patient condition and smoke exposure

Accommodation request language

Demand Letter

Legal basis and requested accommodation

Exposure details, log, and attachments

Response deadline and potential remedies

Sample Doctor’s Note (should be on doctor’s stationery) [ Date ] To Whom It May Concern: [ Patient ] has been under my care for [ describe period of time (e.g., months, years) ]. [ Patient ] has [ name of condition ] which significantly interferes with [ her/his ] ability to [ describe limitations, especially related to respiratory impairment ]. As a result [ patient ] qualifies as disabled under the federal Fair Housing Act and the California Fair Employment and Housing Act. [ Patient ] has reported to me that tobacco smoke is drifting into [ her/his ] unit from [ identify where smoke is coming from (e.g., neighboring unit) and how it is entering the unit, if known (e.g., through the heater vent ) ]. [ Patient ] says that the smoke enters [ her/his ] apartment [ describe the frequency (e.g., every day) ]. Due to [ patient ]’s condition, exposure to tobacco smoke is detrimental to [ her/his ] health and increases the risk of [ patient ] suffering an adverse event, such as [ describe negative health impact ]. I urge you to grant [ patient ]’s accommodation request to [ describe the accommodation request (e.g., ban smoking in the common areas, allow to move to a vacant unit away from the drifting smoke, make the surrounding units nonsmoking, release from rental agreement so can move, etc.) ]. This accommodation is necessary to ameliorate the conditions of [ patient ]’s disability. Sincerely, [ Signature ] Dr. [ doctor’s name ] Sample Demand Letter [ Tenant’s Name ] [ Address ] [ Phone Number ] [ Date ] Dear [ Landlord or Property Manager ]: I am writing to request that you make a reasonable accommodation for my disability. Both federal and state fair housing laws require that housing providers grant reasonable accommodation requests for tenants with disabilities. 42 U.S.C. § 3604(f)(3)(b) and Cal. Gov’t Code § 12927(c)(1). See also Giebeler v. M&B Associates, 343 F.3d 1143, 1147, 1156-8 (9th Cir. 2003). I have a disability that significantly impairs my ability to breathe, and this condition is made worse by exposure to tobacco smoke. Tobacco smoke has been entering my unit and is coming from [ identify where smoke is coming from (e.g., neighboring unit) and how it is entering your unit (e.g., seems to be coming in through the heater vent ) ]. The smoke enters my apartment [ describe the frequency (e.g., every day) ]. A log is attached listing the dates of my exposure. This continuous exposure to secondhand tobacco smoke has aggravated my disability by [ describe your symptoms ]. A doctor’s letter is attached, documenting my condition and symptoms. The U.S. Surgeon General has concluded that there is no safe level of exposure to secondhand smoke. See U.S. Dept. of Health and Human Services. News Release, New Surgeon General’s Report Focuses on the Effects of Secondhand Smoke. June 27, 2006. Available at: www.hhs.gov/news/press/2006pres/20060627.html. In addition, the California Air Resources Board declared secondhand smoke a “toxic air contaminant,” which means that it may cause and/or contribute to death or serious illness. See Air Resources Board, Cal. Dept. of Environmental Protection Agency. News Release, Environmental Tobacco Smoke: A Toxic Air Contaminant. Oct. 18, 2006. Available at: www.arb.ca.gov/newsrel/nr012606.htm. California courts and the U.S. Department of Housing and Urban Development (HUD) have required that reasonable accommodations be made for persons whose disabilities are aggravated by drifting tobacco smoke. See County of Fresno v. Dept. of Fair Employment and Hous. Comm’n, 226 Cal. App. 3d 1541 (employer liable for failure to accommodate two employees whose disabilities were aggravated by co-workers’ smoking); in re U.S. Dep’t of Hous. and Urban Dev. and Park Tower Apartments, HUD Case Nos. 05-97-0010-8 and 05-97-11-0005-370 (1998) (in response to complaint by disabled tenant with respiratory illness, landlord was required to include no-smoking term in all new tenants’ leases). I am requesting

FAQs

What information should be included in the doctor’s note?

The doctor’s note template requires the patient’s treatment period, the specific condition, how drifting tobacco smoke impairs breathing, and a statement that the patient qualifies as disabled under the relevant federal and California laws.

What should the tenant’s demand letter request?

The demand letter requests a reasonable accommodation related to disability aggravated by drifting tobacco smoke, such as banning smoking in common areas, moving the tenant to a different unit away from the smoke, or making surrounding units non-smoking.

What evidence and documents can be attached to the demand letter?

The template recommends attaching a doctor’s letter documenting the condition and symptoms, and a log listing the dates of tobacco smoke exposure; it also references supporting research and relevant legal decisions.

Aug 30, 2026

Upload by Berry Peter