Fillable Medical Verication Form NEW YORK CITY HOUSING AUTHORITY (City of New York)

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Medical Verication Form NEW YORK CITY HOUSING AUTHORITY (City of New York)

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NYCHA 040.426 (Rev. 7/18/19v2) VS_20120112 REASONABLE ACCOMMODATION - MEDICAL VERIFICATION FORM
Page 1 of 4
NEW YORK CITY HOUSING AUTHORITY
Medical Verification Form
A. Case #:
B. You, the head of household, have indicated that a reasonable accommodation is required because of mental,
developmental or emotional disability.
AUTHORIZATION TO RELEASE INFORMATION
I, the above named Tenant, authorize the health care provider listed below to provide NYCHA with the following
information about the person with a disability named above, as it relates to the disabled person’s reasonable
accommodation request.
• Information regarding the patient’s need for the reasonable accommodation listed above, or a
recommendation for an alternative reasonable accommodation
D.
a. Last Name b. First Name c. MI
C. SECTION A: AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION
1. Name of the household member for whom the accommodation is requested:
2. Last 4 digits of Social Security Number 3. Date of Birth
(mm/dd/yyyy)
A translation of this document is available in your management oce.
La traducción de este documento está disponible en la Ocina de Administración de su residencial.
Перевод этого документа находится в Вашем домоуправлении.
所居公房管理處備有文件譯本可供索取。
所居公房管理处备有文件译本可供索取。
The English language version of this document is the ocial, legal, controlling document.
Any translated version of this document is not an ocial document.
Reset
NYCHA 040.426 (Rev. 7/18/19v2) VS_20120112 REASONABLE ACCOMMODATION - MEDICAL VERIFICATION FORM
Page 2 of 4
The Health Care Provider is authorized to release information to NYCHA at the office and address listed below.
The tenant/applicant authorizes release of this information, even though it may otherwise be confidential
under New York State Law or the Privacy Rule of the Health Insurance Portability and Accountability Act of
1996 (HIPAA).
•
This Authorization does not waive any professional relationship confidentiality.
• This Authorization can be revoked by me at any time, by written statement to the Health Care Provider.
• The information provided to NYCHA will be in response to this form, and can either be written and attached
to this form or provided as additional documents or responses to follow-up inquiries from NYCHA.
• This Authorization is for the limited time and purpose of allowing NYCHA to consider and respond to my
reasonable accommodation request. In any event, this authorization expires one year from the date signed.
1. Signature of Family Member with Disability
3. Signature of Parent or Guardian (if applicable)
(mm/dd/yyyy)
2. Date
(mm/dd/yyyy)
4. Date
F.
This release shall not constitute a waiver of the confidentiality of our professional relationship.
E. I hereby authorize you to provide the New York City Housing Authority with a description of the need for a
reasonable accommodation.
NYCHA 040.426 (Rev. 7/18/19v2) VS_20120112 REASONABLE ACCOMMODATION - MEDICAL VERIFICATION FORM
Page 3 of 4
a. Health Care Provider b. Social Worker
G. SECTION B: HEALTH CARE PROVIDER / SOCIAL WORKER RESPONSE
1. SOCIAL WORKER/ HEALTH CARE PROVIDER INFORMATION
2. Name of Social Worker/Health Care Provider
Please have the health care provider or social worker complete this section for the household member listed on page 1
for whom you are requesting an accommodation.
a. Last Name b. First Name c. MI
d. Your Agency Affiliation
e. Agency’s Address
f. Office Phone g. Professional License #
a. How long has this person been your patient /client?
b. When did you last evaluate this patient / client?
c. Does your patient/client have a physical, medical, mental or psychological impairment
or history of record of such impairment that requires accommodation?
d. If applicable: please explain which major life activities may be affected.
3. PATIENT /CLIENT INFORMATION:
4. BRIEF DESCRIPTION OF CONDITION AND REQUIRED ACCOMMODATION:
(mm/dd/yyyy)
1. Yes 2. No
Describe, without disclosing the disability, how the accommodation would suit the impairment in the space provided below.
If you would like to provide additional information, please attach it to this form.
NYCHA 040.426 (Rev. 7/18/19v2) VS_20120112 REASONABLE ACCOMMODATION - MEDICAL VERIFICATION FORM
Page 4 of 4
5. If the impairment is temporary or if you are not sure of how long your client/patient will be impaired, please explain why in the
space provided below. If you would like to provide additional information, please attach it to this form.
a. Signature of Health Care Provider/Social Worker
b. DATE
(mm/dd/yyyy)
b. If ‘yes’, how is the accommodation linked to the person’s impairment? (Note: in order for an accommodation to be considered,
a connection must be made between the impairment and the requested accommodation. You do not have to disclose the full
diagnosis or exact impairment). If necessary, attach additional information to this form.
a. Is this impairment temporary? 1. Yes 2. No 3. Unable to make determination
6. I certify that the information above is accurate and true to the best of my knowledge.
c. Health Care Provider: Place medical stamp below.
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Medical Verication Form NEW YORK CITY HOUSING AUTHORITY (City of New York)

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Completed 31 August 2021

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