Reasonable Accommodation Request Form

Instructions

The Patient Advocate Certification Board (PACB) provides reasonable accommodations in accordance with the Americans with Disabilities Act (ADA) to qualified candidates with documented disabilities.

All PACB exams are delivered remotely through a secure, live-proctored platform. Therefore, accommodations must be compatible with this format.

Please complete and submit this form at least 30 days prior to the start of your exam cycle. Incomplete requests or those submitted late may delay processing and may result in deferral to the next exam cycle.

Please do not attempt to schedule your examination until you receive an email about the status of your accommodation request and the next steps you must take to schedule your examination.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Indicate whether the disability is temporary or permanent.*

TemporaryPermanent
Provide a detailed explanation of how the documented impairment interferes with your ability to take the exam under standard testing conditions
You must provide official documentation from a qualified professional (e.g., physician, licensed psychiatrist, licensed psychologist, etc.). Documentation may include an official report confirming the presence, nature, and extent of your disability, along with a description of the specific accommodations recommended. Please also include documentation (e.g., documentation from another organization similar to the PACB) of any past testing accommodations that you have received for standardized testing. If you do not provide appropriate documentation, your accommodation request may be delayed or denied.*
Describe the nature of the disability and how it affects your ability to take a remotely proctored, computer-based exam.*
Section 3 – Requested Accommodations

Please check all accommodations you are requesting and provide details where indicated:
Section 4 – Supporting Documentation

Please attach documentation from a qualified healthcare professional that:
- Identifies your disability or functional limitation(s);
- Explains how it impacts your exam performance in a remotely proctored exam environment;
- Recommends specific accommodations with a clear rationale.
Documentation must:
- Be on official letterhead, signed, and dated;
- Be issued within the past 3 years (or be accompanied by a current professional statement confirming the condition remains stable for permanent conditions).
Attach documentation here
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Qualifications of the Professional Who Diagnosed Your Disability
The diagnosing professional should be a qualified, licensed, and/or certified practitioner practicing within their scope of competence in a field that is relevant to your disability.*
Specific accommodations prescribed to you by the qualified professional.*
Exam Testing Cycle for which I need accommodations*

Fall 2025Spring 2026Fall 2026
Applicant Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
By submitting this form, I understand that:
- Correspondence regarding my accommodation request may be sent to me via email. The Patient Advocate Certification Board is not liable for the disclosure of confidential information that may arise as a result of email transmission (e.g., your email is read by coworkers, employers, etc.).
- PACB may verify the credentials of the evaluating professional and the authenticity of the documentation.
- My request will not be considered complete until all required documentation is submitted.
- Accommodations are not guaranteed and will be determined on a case-by-case basis.
No exam appointment will be authorized until an approved Testing Accommodations Agreement has been signed and returned.
Date*

MonthDayYear
Date
Section 5 – Certification and Signature

By signing below, I certify that:
- The information provided in this form is true and complete;
- I authorize PACB to contact my evaluator, if necessary, to verify information;
- I understand that PACB may approve, modify, or deny requests based on documentation and technical feasibility;
- I consent to PACB using this information only for the purpose of reviewing and implementing accommodations;
- I understand that misrepresentation of disability status or misuse of accommodations may result in exam invalidation and disciplinary action.
Candidate Signature*

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Select the exam cycle for which you are requesting accommodations:

Spring 2026Fall 2026Spring 2027
Should be Empty:

Provide a detailed explanation of how the documented impairment interferes with your ability to take the exam under standard testing conditions

Qualifications of the Professional Who Diagnosed Your Disability