Attachment 2
SAMPLE REQUEST FOR MEDICAL DOCUMENTATION FOR PAS REQUEST(Insert Date)
From: (Insert Supervisor’s Title and Name)
To: (Insert Requestor’s Title and Name)
Subj: REQUEST FOR CURRENT MEDICAL DOCUMENTATION
Ref: (a) 29 Code of Federal Regulations § 1614.203(d)(5)
1. On (insert request date here), you submitted a request for Personal Assistance Services(PAS), and you identified your targeted disability as (insert targeted disability here). You haverequested the following services for the following time period: (Insert PAS requested - be sure toadd in any specific information to describe the services request or any notable details from therequest process).
2. In accordance with reference (a), the goal of providing PAS is to assist employees in
performing activities of daily living during work hours and work-related travel to those who needthem because of certain disabilities. Reference (a) also indicates that eligibility for receiving
PAS, absent undue hardship on the agency, is dependent on an employee having a targeted
disability and requiring the service as a result of the employee’s limitations. At this time, I do
not have enough information regarding your need for PAS, so the purpose of this letter is torequest information regarding your current medical condition and how the PAS would allow you
to participate in the workplace or in job-related travel. This information will assist me indetermining your eligibility to receive PAS and if required, what services may be effective.
3. Please ask your healthcare provider to provide the following information:
a. Identify the disability or disabilities for which PAS are required;b. List the daily activity or activities for which PAS are required;c. Describe how the requested assistance will enable you to perform activities of dailyliving which occur in the workplace or during work-related travel.
4. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), which became
effective 14 April 2003, imposes new requirements on medical providers, employers, healthplans and plan administrators to ensure that your individual medical and health information iskept confidential. In adhering to this regulation, your health provider will not release medical
documentation without your permission.
5. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers andother entities covered by GINA Title II from requesting or requiring genetic information of anindividual or family member of the individual, except as specifically allowed by this law. To
comply with this law, we are asking that you and/or health care professional not provide any
genetic information when responding to this request for medical information. "Geneticinformation," as defined by GINA, includes an individual's family medical history, the results ofan individual's or family member's genetic tests, the fact that an individual or an individual's
For Official Use Only - Privacy Sensitive:
Any misuse, unauthorized disclosure or unauthorized access may result in civil or criminal penalties, or both.

Subj: REQUEST FOR MEDICAL DOCUMENTATION
family member sought or received genetic services, and genetic information of a fetus carried byan individual or an individual's family member or an embryo lawfully held by an individual orfamily member receiving assistive reproductive services.
6. Please provide me with the requested documentation from your healthcare provider within 15calendar days of your receipt of this letter. If you have any questions or concerns, please contact
me or (Insert name of RA POC) at (insert RA POC information).

(Insert Supervisor’s Name/Signature block)
Copy to:(Insert parties with a need-to-know)

Acknowledgement of receipt:

Employee’s signature

Date

For Official Use Only - Privacy Sensitive:
Any misuse, unauthorized disclosure or unauthorized access may result in civil or criminal penalties, or both.