Any medical and/or disability-related information shared about this patient for accommodation
evaluation will be keptcondential.
*Please select one of the options below
_____ Health professional is not required to complete this form. He/She may submit medical
correspondence validating the high-risk medical condition via fax, email, facilities medical form,
and/ordocumentation.
_____ Health professional may alternatively complete attestation below.
[______________________________________________________________________] is a patient under my
medical care. My patient has a pre-existing medical condition that places them at greater risk
of severe illness if they contract COVID-19, including certain pre-existing medical conditions
as described by the CDC, or those “Others At Risk” which include pregnantwomen.
Please provide any additional information that might be useful in processing this accommodation request,
including any potential alternatives to the quarantine accommodations suggested above: _________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Signature of Health Care Provider (sign and print name): Date:
Type of Practice: Practice Name & Address: Phone Number (with area code):
© 2020 Wells Fargo Bank, N.A. All rights reserved. Member FDIC. 09/20 IHA-5198082
TO HEALTH PROFESSIONAL:
The employee identied above has requested time to self-quarantine from their existing on-site job duties on the basis
that the employee or a family member within their household is at risk due to COVID-19. We need additional information
in order to evaluate thatrequest.
Please do not provide any information about the employee’s medical condition (or that of their family member) beyond
what is necessary to respond to the questionsbelow.
If you determine that the employee has a medical condition that makes them unable to perform one or more of the
essential functions of their position in light of the COVID-19 pandemic, including the ability to work on-site or otherwise
without posing a direct threat to the employee, please complete the corresponding questions to determine what
accommodation, if any, is needed. Please do not provide information relating to any other medicalconditions.
Patient’s Name
2 of 2
Note: 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 specically 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 dened 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.
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