Amazon Healthcare Provider Form for Accommodation Request Completed Form Examples and Samples

To Whom It May Concern, I am writing on behalf of my patient, Jordan Smith (DOB: 05/12/1988), who is currently employed at Amazon under the alias 'jsmith88'. Jordan presented to our clinic on January 15, 2026, for a follow-up evaluation regarding a persistent lumbar strain that significantly impacts their ability to perform daily work activities. The patient currently suffers from significant mobility limitations that make it difficult to maintain a standing position for extended periods. Specifically, Jordan is restricted to no more than 2 hours of standing per shift and cannot lift or carry objects weighing more than 15 pounds. These restrictions are expected to be temporary as the patient undergoes physical therapy; we anticipate these limitations will be necessary from February 1, 2026, until May 31, 2026. Furthermore, due to the nature of their role, Jordan requires additional breaks throughout the shift—specifically 2 breaks, each lasting no more than 10 minutes—to perform required spinal decompression stretches. Please note that these restrictions do not impact the patient's cognitive or executive functioning; Jordan remains fully capable of performing all desk-based or computer-related tasks. We have advised Jordan to avoid all climbing of ladders or stairs during this recovery period. Our office is located at 123 Wellness Way, Suite 400, Springfield, IL 62704. You may reach our office administrator, Dr. Elena Rodriguez (MD, Orthopedics), at 555-0199 or via fax at 555-0198 for any clarifying questions regarding these medical orders. Sincerely, Dr. Elena Rodriguez.