Disability Packet Disability Packet Your first name(Required)Middle nameLast name(Required)Patient D.O.B.(Required)Today's date MM slash DD slash YYYY Person Receiving Medical Records(Required)If records are being requested by a legal guardian or caregiver, the Power of Attorney forms need to be sent to NCF before records can be released.FAX NumberEmail address(Required) Enter Email Confirm Email Records to sendRecords to send 1 Office Notes Laboratory Tests Insurance Information Billing Statements Records to send 2 MRI EEG CAT Scan Forms Records to send 3 EMG MRA Letter Other Other Records Needed…Request SpecificationsReason for RequestRecords Start Date MM slash DD slash YYYY Records End Date MM slash DD slash YYYY Expiration Date MM slash DD slash YYYY Authorization to Release Protected Health Information (PHI) I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. By signing this authorization, I authorize Neurology Center of Fairfax, Ltd. to use and/or disclose certain protected health information (PHI) about me. When my information is used or disclosed pursuant to this authorization it may be subject to redisclosure by the recipient and may no longer be protected by federal HIPAA privacy rules. I have the right to revoke this authorization in writing. My written revocation must be submitted to the Privacy Officer at the Neurology Center of Fairfax: 3020 Hamaker Ct #400, Fairfax, VA 22031. This authorization will automatically expire 1 year from date signed unless otherwise indicated.Authorized Name(Required)Consent(Required) By checking this box, I – the authorized person named here – am signing this document.Date(Required) MM slash DD slash YYYY Disability InformationDisability form titleWhich NCF doctor are you requesting to review your disability evaluation?Date symptoms began MM slash DD slash YYYY Date disabilty began MM slash DD slash YYYY Date diagnosis was made MM slash DD slash YYYY Diagnosis for disabilityLast day worked MM slash DD slash YYYY Working part-time? Yes No Date part-time work began MM slash DD slash YYYY What is your current job title, description, and necessary duties?What functions of your job are you unable to complete due to your condition or disability?Which symptoms of your condition are preventing or restricting your ability to perform the duties of your job?What accommodations are you requesting? Please be specific.What aspects of your job can you not perform?Are you working? Yes No Who certified work disability?When were you certified for work disability? MM slash DD slash YYYY Are applying for disability or accommodations? Short Term Disability Long Term Disability Accommodations Why are you disabled?What physical and/or mental activities are you unable to perform?What aspects of daily living are limited or cannot be performed?List cognitive and/or memory problemsAdditional informationUnder ADA, major life activities refer to essential functions or tasks that are significant to daily life. A person is considered to have a disability if a physical or mental impairment substantially limits one or more of the below activities. FOR THOSE THAT APPLY TO YOU SELECT THE FUNCTIONS THAT ARE IMPAIRED:Caring for Oneself – Personal hygiene Grooming Dressing Eating Other (please fill in more info below) Performing Manual Tasks – Everyday physical tasks Lifting Carrying Organizing Other (please fill in more info below) Walking – Ability to move from one place to another Independently With assistance Other (please fill in more info below) Seeing – Visual Functioning Reading Recognizing faces Detecting objects Other (please fill in more info below) Hearing – Auditory Processing Understanding speech Perceiving sounds Other (please fill in more info below) Speaking – The ability to communicate through verbal speech Clear articulation Ability to be understood Other (please fill in more info below) Breathing – The ability to breathe without difficulty Asthma COPD Other (please fill in more info below) Learning – Cognitive Processing Ability to understand Ability to remember Ability to apply information Other (please fill in more info below) Working – The ability to perform the tasks required by one’s job or occupation I have specific accommodations needed for my work tasks Please list the accommodations neededConcentrating Ability to focus, stay on task, and avoid distractions Other (please fill in more info below) Sleeping Ability to sleep and stay rested for daily activities Other (please fill in more info below) Thinking – Cognitive Functions Difficulty with reasoning, problem-solving, and planning Other (please fill in more info below) Communicating – Using language to interact with others Difficulty with verbal communication Difficulty with non-verbal communication Other (please fill in more info below) Major Bodily Functions – Select the functions affected. Immune system (e.g., HIV/AIDS, autoimmune disorders) Normal cell growth (e.g., cancer, abnormal growths) Digestive system (e.g., gastrointestinal disorders) Bowel and bladder functions Neurological functions (e.g., seizures, brain injuries) Circulatory functions Endocrine functions (e.g., diabetes, thyroid disorders) Reproductive functions Other functions Please list other bodily function affected.Other activities or functions affectedIf you selected ‘other’ above and need to explain further, do so here:Rev 2.17.2025PhoneThis field is for validation purposes and should be left unchanged.