Fillable A. Case # NEW YORK CITY HOUSING AUTHORITY (City of New York)

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A. Case # NEW YORK CITY HOUSING AUTHORITY (City of New York)

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NYCHA 070.171 (Rev. 5/11/18 v4) VS_20120810
Page 1 of 3
A. Case #
NEW YORK CITY HOUSING AUTHORITY
APPLICATIONS AND TENANCY ADMINISTRATION DEPARTMENT
Dear Applicant:
You have indicated that you or a member of your household requires an accommodation because of a health
condition. We need to verify this information with either a health care provider or social worker.
This information is not used in determining whether you are eligible for an apartment. It is only used to determine
whether you are entitled to the requested accommodation.
The family member with the health condition (or his/her parent or legal guardian) should review this
form and sign the authorization below then give the form to their health care provider or social worker.
C.
B.
Re: REASONABLE ACCOMMODATION VERIFICATION LETTER
The New York City Housing Authority will use this information only for the purpose of oering you an apartment
which accommodates your needs and will keep it condential pursuant to law. If you choose not to authorize the
release of this information, we will no longer consider your request for a reasonable accommodation.
D. AUTHORIZATION TO RELEASE INFORMATION
-----------------------------------------------------------------------------------------------------------------------------------------------------
Last First MI
1. TO:
2.
Name of Social Worker or Health Care Provider
3. RE:
Name of Client/Patient
I hereby authorize you to provide the New York City Housing Authority with the information requested
on the back of this form about the following health condition. This release shall not constitute a waiver
of the condentiality of our relationship.
4. I wish to receive an Extra Bedroom
Lower Floor
Retrotted Apartment
(select all that apply)
Other Accommodation (Explain):
5.
6. Date 7. Signature of Client/Patient or Parent/Legal Guardian 8. Relationship to Applicant
Reset
NYCHA 070.171 (Rev. 5/11/18 v4) VS_20120810
Your Name
(Last name) (First name) (Title)
Your Organization
Organization’s Address
Office Phone # ( )
1. How long has this person been your patient/client?
2. When did you last evaluate this patient/client?
3. Your patient/client has told us (s)he needs an accommodation (see front of this form) because of health condition(s).
Is this true? Yes No
4. Please explain whether your patient/client’s requires an accommodation, the accommodation required and how
it accommodates the health condition.
HEALTH CARE PROVIDER / SOCIAL WORKER RESPONSE FORM
We would appreciate your cooperation in furnishing the requested information regarding the individual named on the
authorization of this form. Please mail the completed form directly to us at the address indicated above.
NEW YORK CITY HOUSING AUTHORITY
APPLICATIONS AND TENANCY ADMINISTRATION DEPARTMENT
Page 2 of 3
Case #
Client Name:
NYCHA 070.171 (Rev. 5/11/18 v4) VS_20120810
HEALTH CARE PROVIDER: CERTIFICATION
I certify that the information above is accurate and true to the best of my knowledge.
Name
License Number
Health Care Provider: Place Medical Stamp below.
5. Is this health condition temporary?
Yes, please explain and estimate duration No
6. If your patient/client’s requested accommodation is based on a need for medical equipment, please list below
all medical equipment currently used by your patient/client :
Yes No
Signature of Health Care Provider/Social Worker
Page 3 of 3
(mm/dd/yyyy)
Date
(Last name) (First name) (Title)
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A. Case NEW YORK CITY HOUSING AUTHORITY (City of New York)

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Completed 31 August 2021

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