Iowa Admin. Code agency 161, ch. 9, app A
Request for Assistance Animal as a Reasonable Accommodation in Housing: Health Care Professional Form
Requester's Name: __________________________________________________________________
Address: __________________________________________________________________________
Telephone: _____________________ E-mail: __________________________
I, ________________________________, intend to request that _______________________________ permit me to keep an assistance animal as a reasonable accommodation in housing for my disability. In connection with that application, I am requesting that you complete this form regarding my disability.
_______________________________________________
Requester's Signature
____________________________
Date
TO BE COMPLETED BY HEAL TH CARE PROFESSIONAL
1. Does the individual identified above have a disability?
[] Yes [] No
2. If yes, is the need for an assistance animal related to that disability? For example, does or would an assistance animal alleviate one or more of the symptoms or effects of the disability?
[] Yes [] No
By signing below , the undersigned health care professional/licensee certifies that he/she 1) has met with the patient or client in person or by telemedicine, 2) is sufficiently familiar with the patient or client and the disability , and 3) is legally and professionally qualified to make the finding. Health Care Provider's Name (printed): ________________________________________
Signature: ________________________________________________________
Date: _______________________
References: Iowa Code sections 216.8B and 216.8C
Resources: https://icrc.iowa.gov/, 515-281-4121, 1-800-457-4416
This document may contain privileged and confidential information and/or protected health information intended solely for the use by the recipient housing provider. Please exercise care to avoid dissemination.
Iowa Admin. Code agency 161, ch. 9, app A