Fillable DISABILITY VERIFICATION FORM (Form 1) Medical Provider Verification (Lone Star College System)

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DISABILITY VERIFICATION FORM (Form 1) Medical Provider Verification (Lone Star College System)

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The DISABILITY VERIFICATION FORM (Form 1) Medical Provider Verification (Lone Star College System) form is 16 pages long and contains:

  • 4 signatures
  • 49 check-boxes
  • 246 other fields

Country of origin: US
File type: PDF

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Disability Verification Form (Form 1)
Page 1 of 5
DISABILITY VERIFICATION FORM (Form 1)
Medical Provider Verification
Dear Health Care Professional,
One of your patients is a student at Lone Star College requesting a disability-based academic
accommodation. Accommodations are made for qualified students with a disability in order for
them to equally participate in all programs and services offered by the College to ensure
compliance with all applicable disability laws. In order for the Disability Services Office to
determine the student’s accommodation eligibility, we need your clinical assessment/diagnosis of
the student. You may fax us a copy, but our records must include an original with your signature
and business card. In addition to the form provided, you may provide supplemental information
on your letterhead.
In order for the student to be certified as eligible, the documentation must show how the disability
substantially limits one or more major life activities. Current and relevant information is required
in order to determine the appropriate reasonable accommodation that may be offered to the student.
All information should be completed by a medical provider qualified to diagnose and treat
the student’s disability.
Please provide the following:
1.
A completed and signed Provider Verification packet for each disability and
2.
Staple your business card to each Provider Verification packet.
The information you provide will be kept confidential in accordance to the Family Education
Rights and Privacy Act (FERPA) and may be released to the student upon written request for
records.
If you have any questions regarding this form or opportunities for the student, please contact
Disability Services at the information listed below. We may also contact you directly for
supplemental information if necessary to make a determination.
Thank you for your assistance,
*The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual
except as specifically allowed by this law. To comply with this law, we are asking that you not provide any
genetic information when responding to this request for medical information. “Genetic information”, as defined
by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic
tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an
individual or family member receiving assistive reproductive services.
Disability Verification Form (Form 1)
Page 2 of 5
I, , authorize my medical provider to release to Lone
Printed Student Name
Star College’s Disability Services Office the medical information requested on this form for the
purpose of determining appropriate accommodations for my disability while a student at Lone
Star College.
Patient Signature: Date:
Student Signature
Provider Verification of Physical/Medical Disability
Student Name: Student ID:
To the Student: The form below the line must be completed by your medical provider who is
qualified to diagnose and treat your disability. The Disability Services Office reserves the right to
request additional documentation or contact your provider for additional information. If this form
is completed by anyone other than a qualified licensed professional, the information will not be
used to support your accommodation request. Inaccurate and incomplete documentation may
hinder the College’s ability to accommodate you based on its policies and procedures.
Please sign the box below to give your medical provider authorization to release information to
the Disability Services Office.
TO BE COMPLETED BY MEDICAL PROVIDER
Is the student currently under your care? No Yes If yes, for how long?
What is the diagnosis/impairment/condition? (Please describe and use ICD 10 diagnostic codes
and or APA DSM 5)
Date(s) of Onset:
click to sign
signature
click to edit
Disability Verification Form (Form 1)
Page 3 of 5
A.
FUNCTIONAL LIMITATION CHART
Reminder: Please identify functional limitations without regard for mitigating measures (i.e.,
medications). For intermittent conditions, assess functional limitations based on a picture when all
symptoms are active. Use an “X” to indicate level of impact on major life activities.
Major Life
Activities
No Impact
Moderately
Impacts
Substantially
Impacts
Unknown
Communicating
Concentrating
Hearing
Learning
Manual Tasks
Reading
Seeing
Thinking
Walking
Working
Sitting
Other:
What are the specific functional limitations resulting from the disability’s impact on the major life
activities in a learning environment (e.g. unable to handle stairs, miss class due to side effects from
disability or medication, unable to sit for long periods of time)?
Are the functional limitations permanent? No Yes If no, what is the anticipated date of
resolution?
Is the student currently undergoing treatment? No Yes If yes, please describe the type
of treatment and list any medications and possible side effects that may affect the student in an
academic setting:
Disability Verification Form (Form 1)
Page 4 of 5
B.
FUNCTIONAL OR BEHAVIORAL PRESENTATION CHART
Please use an “X” to indicate additional limitations or behavioral manifestations.
Limitations and Behavioral
Manifestations
Not an Issue
Moderate
Issue
Issue
Unknown
Cognitive Processing
Memory
Processing Speed
Meeting Deadlines
Attending class
Organization
Reasoning
Stress
Sleep
Appetite
Other:
What are the specific behavioral limitations resulting from the disability’s impact on the major life
activities in a learning environment?
Are the behavioral limitations permanent? No Yes If no, what is the anticipated date of
resolution?
Is the student currently undergoing treatment? No Yes If yes, please describe the type
of treatment and list any medications and possible side effects that may affect the student in an
academic setting:
Disability Verification Form (Form 1)
Page 5 of 5
PLEASE ATTACH
BUSINESS CARD
HERE
Medical Provider Information:
First Name: Last Name:
Title: State License Number:
Address: City: State:
Zip: Phone: Fax:
Physician/Provider Signature: Date:
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signature
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Student Information & Disability Accommodation Request (Form 2)
Page 1 of 2
STUDENT INFORMATION & DISABILITY ACCOMMODATION REQUEST (Form 2)
Accommodations Requests also include requests for Auxiliary Aids and Services
Student Information:
Name:
Student ID: Date of Birth:
Address:
Primary telephone: Email:
Do you give permission to leave confidential information on voicemail? Y N
Would you like to receive email updates and reminders from our office? Y N
Emergency Contact Information (optional):
Are you currently enrolled at Lone Star College? Y_N
If yes, check campus:
Cy-Fair
Kingwood
Cypress Center
Montgomery
North Harris
Process Technology Center
East Aldine Center
Tomball
Creekside Center
University Park
Conroe Center
EMCID Center
Greenspoint Center
Fairbanks Center
Victory Center
Atascocita Center
Houston North
Westway Park Technology Center
If no, when will you enroll and where? _
Career Goal or Major:
Disability Information:
What is your disability or disabilities?
Check All That Apply:
Learning Disability
Asperger’s/Autism
Deaf/Hard of Hearing
Ment
al Health
Blind/Low Vision
Traumatic Brain Injury
Physical/Mobility
Other
What accommodations will assist you in your academic life?
Check all support you receive and list corresponding contact information:
DARS (Department of Assistive and Rehabilitative Services)
VA
MHMR (Mental Health Services)
OTHER
Agency Name:
Contact Name:
Telephone:
Agency Name:
Contact Name:
Telephone:
Date_
Semester
Year _
Student Information & Disability Accommodation Request (Form 2)
Page 2 of 2
For Disability Services Office Use Only:
Did student provide and attach requested documentation to be eligible for accommodation? Y N
If no, was student provided with a Disability Verification Form and reminded of his or her responsibility to obtain said
documentation prior to being eligible for accommodation? Y N
Did Disability Services provider and student discuss the student’s class schedule and specify which courses he or she
desired accommodation(s) for? Y N
DSO Provider: Date:
STUDENT AGREEMENT REGARDING DISABILITY ACCOMMODATION REQUESTS
Please read carefully and initial each statement below indicating your agreement:
I understand that I must submit a request for accommodation and provide requested documentation of my disability
to the Disability Services Office at the college where I am enrolled in order to be eligible to receive accommodation(s).
I understand that accommodation requests with approved documentation may take 2-4 weeks to be processed and, if
possible, implemented by the College.
I understand that, for the Disability Services Office to provide effective accommodation(s) for me, information related
to my enrollment, courses, and disability will be used by the Disability Services Office for purposes of preparing or
providing reasonable accommodation.
I consent to the College’s Disability Services Offices communicating regarding my disability as it pertains to my
accommodations, educational needs, and progress.
I consent to the Disability Services Offices communicating with my instructors regarding proposed or approved
accommodation(s), my educational needs, and progress reports as needed. Unless specifically requested in writing, the
Disability Services Office will not communicate my disability outside of personnel in the College’s Disability Services
Office.
I understand that I must meet with the Disability Services Office each semester I am enrolled to be eligible to receive
accommodation(s).
Student Signature Date
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signature
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Request for Continued Services (Form 3)
Page 1 of 2
STUDENT REQUEST FOR CONTINUED SERVICES (Form 3)
This Form is for students who have previously completed the College’s two-step process for receiving accommodation from the Disability Services
Office (DSO). If you have not completed the College’s two-step process, please use the Student Information & Disability Accommodation Request
(Form 2). Please note that submission of this form does not automatically grant accommodation. Once submitted, a DSO provider will review this
Form and determine whether you are eligible for accommodation. Eligible students will receive an accommodation letter from the DSO for the
current semester.
Student Information:
Name: Today’s Date:
Student ID: Date of Birth:
Address:
Primary telephone: Email:
When did you receive accommodation at Lone Star College? Semester Year
College of enrollment:
Cy-Fair
Kingwood
Cypress Center
Montgomery
North Harris
Process Technology Center
East Aldine Center
Tomball
Creekside Center
University Park
Conroe Center
EMCID Center
Greenspoint Center
Fairbanks Center
Victory Center
Atascocita Center
Houston North
Westway Park Technology Center
Disability Information:
Has your disability changed? Y N
If Yes, please explain:
Are you submitting updated documentation? Y N
Are you requesting the same accommodation(s) previously granted by the College? Y N
If No, please explain:
Is your current class schedule attached? Y N
Request for Continued Services (Form 3)
Page 2 of 2
For Disability Services Office Use Only:
Did student attach class schedule? Y N
Are student’s previously provided accommodations reasonable for the current classes? Y N
Did student have a change in disability? Y N
If yes, did student provide additional or updated documentation? Y N
Did student request a change in the previously provided accommodation(s)? Y N
If yes, does the change requested require additional or updated documentation? Y N
DSO Provider: Date:
STUDENT AGREEMENT REGARDING DISABILITY ACCOMMODATION REQUESTS
Please read carefully and initial each statement below indicating your agreement:
I understand that I must submit a request for continued services to the Disability Services Office to be eligible to
receive previously granted accommodation each semester.
I understand that changes to my disability or my previously granted accommodation may require me to provide
additional or updated documentation.
I understand that changes to my disability or my previously granted accommodation may take 2-4 weeks to be
processed and, if possible, implemented by the College.
I understand that, for the Disability Services Office to provide effective accommodation(s) for me, information related
to my enrollment, courses, and disability will be used by the Disability Services Office for purposes of preparing or
providing my reasonable accommodation.
I consent to the College’s Disability Services Offices communicating regarding my disability as it pertains to my
accommodations, educational needs, and progress.
I consent to the Disability Services Offices communicating with my instructors regarding proposed or approved
accommodation(s), my educational needs, and progress reports as needed. Unless specifically requested in writing, the
Disability Services Office will not communicate my disability outside of personnel in the College’s Disability Services
Office.
Student Signature Date
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signature
click to edit
Request for Reconsideration (Form 4):
This request must be sent to the Executive Director of Disability Services
Student:
Print Name
Student ID:
Disability Services Office:
College campus
This Request for Reconsideration is for (circle one):
Accommodation Denial or College-proposed Accommodation
---------------------------------------------------------------------------------------------------------------------
Request for Reconsideration – Please describe the circumstances of your request for reconsideration.
Attach all relevant documentation including the Disability Services Office denial of accommodation or
your accommodation letter.
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DISABILITY VERIFICATION FORM (Form 1) Medical Provider Verification (Lone Star College System)

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Completed 4 February 2021

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