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Prudential GL.2015.155: Accommodation Medical Inquiry

When an employer uses Prudential to administer workplace accommodation requests, the employee's health care or rehabilitation provider completes this inquiry to show whether a disability exists and why an accommodation is needed. The provider describes the impairment, the major life activities or bodily functions it limits, the functional limitations and their duration, expected absences and the return-to-work plan.

Who completes it

The employee completes and signs sections 1 and 2. The health care or rehabilitation professional completes sections 3 to 6 and signs as treating professional; Prudential lists doctors, psychologists, nurses, physical, occupational and speech therapists, vocational rehabilitation specialists and licensed mental health professionals.

Submitting and payment

How to submit it
The completed form goes to Prudential Disability Management Services by mail or fax, at the address and fax number printed on each page.
Who pays
The form states the employee is responsible for having it completed at no expense to Prudential.

Good to know

  • An actual diagnosis is not required: section 3 asks whether there is an impairment and what it is, judged in its active state and without mitigating measures such as medication or devices.
  • Section 4 wants each limitation with its expected duration, using the form's example: cannot stand for more than 2 hours at a time, expected to last 4 months.
  • Absence estimates in section 5 should include travel time; if the end date is unknown, give the next office visit for reevaluation.
  • Edition 02/2026, 6 pages. Section 2 is an optional employee authorization letting Prudential share disability claim information with the employer for 24 months.

Get the official form

Download the current version from the source each time; forms change without notice.

Accommodation Medical Inquiry Form

Official pagePDF

How this list is checked

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.

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Frequently asked questions

Does the Prudential accommodation form need a diagnosis?

No. Section 3 asks whether the employee has an impairment and what it is, but notes that actual diagnosis information is not required. The provider answers based on limitations when the condition is active and without mitigating measures such as medication, assistive devices or therapy; ordinary eyeglasses do not count as mitigating measures.

Who can complete Prudential's Accommodation Medical Inquiry Form?

The appropriate professional depends on the disability. Prudential names doctors, including psychiatrists, psychologists, nurses, physical, occupational and speech therapists, vocational rehabilitation specialists and licensed mental health professionals. The professional completes sections 3 to 6 and signs as the treating professional.

Does the employer see what the provider writes?

Yes. The form tells the employee that the employer is entitled to copies of all forms and information Prudential uses to administer its accommodation program. Separately, the optional section 2 authorization lets Prudential share information from an existing disability claim file with the employer.