Disability Verification Form (Form 1)
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:
A completed and signed Provider Verification packet for each disability and
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
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.