Contents of the Template
This template includes the following key sections and points:
- Healthcare Professional Information: Full contact details of the healthcare professional, including name, title, license number, address, phone number, and email.
- Patient Information: Personal details of the patient, including full name, date of birth, address, and contact information.
- Medical Condition: Detailed information about the patient’s medical diagnosis, including ICD-10 code, date of diagnosis, severity, and treatment plan.
- Necessity for a Service Animal: A formal statement confirming the patient’s need for a service animal due to their disability.
- Tasks the Service Animal is Trained to Perform: A list of specific tasks that the service animal is trained to perform for the patient.
- Service Animal Description:Information about the service animal, including type, name, breed, weight, and age.
- HIPAA Release Statement:A statement confirming the patient’s consent under HIPAA for releasing this information.
- Healthcare Professional’s Signature:A space for the healthcare professional to sign and authenticate the letter.
Why Use This Template
- Ease of Use: This template is user-friendly and simple to fill, with clear guidance for all necessary fields.
- Standardized Format: Having a standardized format ensures that all necessary information is included, which helps in avoiding any potential issues or delays.
- Versatility: The template is available in Word, PDF, and Google Docs formats, making it easy to edit, save, and share according to your preference.
- Professional Appearance: Using this template ensures that the Service Dog Letter appears organized and professional, which can help in facilitating a positive response from authorities.
- Individuals with a Disability: This template is most useful for individuals with a diagnosed disability who require a service animal to assist with daily living activities.
- Healthcare Professionals: Doctors, psychologists, psychiatrists, and other healthcare professionals can use this template to write a letter for their patients who need a service animal.
- Housing Accommodation Requests: This template is ideal for individuals who are seeking reasonable accommodation in housing that may otherwise have a no-pets policy.
- Travel Accommodations: Individuals who need to travel with their service animal can use this template to request reasonable accommodation from airlines and other transportation providers.