New York Life Group Benefit Solutions (NYL GBS) administers job accommodation programs for employers, and this questionnaire is how the employee's health care provider supports an ADA or Pregnant Workers Fairness Act request. The provider describes the impairment or pregnancy-related condition, how it limits job duties, how long it will last, current restrictions, and the accommodations or leave recommended.
The employee completes the request form on pages 1 and 2. The health care provider completes the Health Care Provider Questionnaire on pages 3 to 5 (questions 1 to 10) and signs with printed name, specialty and date.
Download the current version from the source each time; forms change without notice.
Americans with Disabilities Act (ADA) and Pregnant Workers Fairness Act (PWFA) Accommodation Request Health Care Provider Questionnaire
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
No. If the request is limited to the accommodations listed in question 2 of the employee form, such as carrying water, extra restroom breaks, sitting or standing, breaks to eat and drink, or lactation breaks, the Health Care Provider Questionnaire does not need to be completed. Any other accommodation needs it.
Whether there is a pregnancy-related condition or impairment, whether it limits major life activities, job duties or access to employment benefits, how long it will last, what restrictions apply, which accommodations are recommended and why they would work, whether a patient on leave could return with accommodations, and any recommended leave pattern.
To NYL GBS Leave Solutions by email, fax or mail, using the contact details printed on the form. The form asks that all pages be returned. NYL GBS runs the employer's accommodation program and shares the information it receives with the employer, which continues the interactive process with the employee.