Contents of the Template
This template includes:
- Physician Information: A dedicated section for the healthcare professional’s details, including name, contact information, and medical license number.
- Patient Information and Medical Details: Clearly organized fields for the patient’s name, date of birth, medical record number, condition(s) diagnosed, date of diagnosis, severity, and ICD-10 code(s).
- Functional Limitations: A table to list the life activities that are significantly impaired due to the patient’s condition.
- Medical Necessity of Service Dog: A section to outline specific tasks the service dog is trained to perform that directly relate to the patient’s disability.
- Statement of Recommendation: A formal declaration by the physician recommending a service dog as part of the patient’s treatment plan.
- HIPAA Disclaimer and Fraudulent Misrepresentation Warning: Standard language regarding patient consent to share health information and the legal risks of misrepresentation.
- Signature and Credentials: Space for the physician’s signature, name, title, medical license number, and date of signature.
Why Use This Template
- Clarity and Organization: This template is organized in a clear and logical manner, making it easy for healthcare professionals to complete.
- Time-saving: It streamlines the process of writing a service dog recommendation, eliminating guesswork and reducing time spent on drafting from scratch.
- Legally Informed: The template is designed to align with common legal requirements, providing a solid starting point for a compliant document.
- Professional Appearance: This template is formatted to be clean and professional, which helps when submitting the document to authorities or housing agencies.
Ideal For
This template is most useful:
- Healthcare Professionals: Doctors or mental health professionals who are recommending a service dog for a patient with a disability.
- Patients with Disabilities: Individuals who have been advised by their healthcare professional to get a service dog and need a formal letter to support their case.
- Housing Requests: When a patient is seeking to live in housing that typically does not allow pets, this letter can be used to request an exception under fair housing laws.
- Travel Accommodations: For patients who need to travel with their service dog and are required to produce documentation of the necessity of the animal for their health and well-being.
