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NYS Office of Temporary and Disability Assistance- TA and SNAP Employment Policy Manual

Appendix A- Page 8 Rev. 3/2022 Sample Cover Letter to Accompany the Request for Medical Information

Date:

RE: (Name of Applicant/Recipient)

DOB:

Dear Health Care Provider:

The above-named individual has been referred to you for evaluation to help determine the extent to which he/she is able to participate in an employment and training (E&T) program and may include job search, job readiness training, work experience, vocational rehabilitation or training, and educational activities including classroom instruction. Additionally, it is important to determine if participation in treatment or rehabilitation is warranted. We also need your assessment of the expected length of the impairment. If the individual has severe impairments that are expected to last at least 12 months or result in death, it may indicate that it would be most appropriate for the district to refer the individual to apply for federal disability benefits. If the individual is able to participate in an E&T program in any capacity, we are also requesting information regarding the nature of any physical or mental functional limitations so that appropriate accommodations may be provided.

Please complete the enclosed medical form. If additional space or clarification is needed in any area, please attach the additional information. Treatment intensity should correspond to the severity of the condition. If, in your opinion, the individual is completely unable to participate in any E&T activities and would not benefit from rehabilitation or treatment, please indicate that so the individual may be referred to the proper agencies and services.

I can be reached at _____________ if you require additional information. Thank you for your time and consideration in this matter. Sincerely, ______________________ Worker Name ______________________ Title