DMS Federal Disability Accommodations Intake Form

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This intake form is for individuals requesting a medical nexus letter or medical opinion in support of a federal disability accommodation request (e.g., VA, DoD, DISA, or other federal agency).

This service provides an independent medical opinion based on record review. It does not guarantee approval of any accommodation request and does not constitute advocacy or legal representation.

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Which best describes your request?* This field is required.

Federal disability accommodation (VA, DoD, DISA, or other federal agency)

Private employer accommodation (ADA)

VA disability compensation claim

Other / Not sure

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Who requested the medical documentation?* This field is required.

Federal agency disability program manager

Human Resources

Supervisor

Attorney

I am requesting this on my own

Other

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Legal Name* This field is required.

First name

Last name

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Date of Birth* This field is required.

Date

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Email Address* This field is required.

example@example.com

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Phone Number* This field is required.

Please enter a valid phone number.

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State of Residence * This field is required.

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Federal Agency or Department* This field is required.(e.g., VA, DoD, DHS, DISA, etc.)

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Your Job Title / Role* This field is required.

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Brief Description of Essential Job Functions* This field is required.Please describe the core duties of your position that are affected by your medical condition.

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What medical condition(s) cause the functional limitations?* This field is required.List provider-diagnosed medical condition(s) only.

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Is the condition service-connected or related to military service?* This field is required.

Yes

No

I’m not sure.

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Treating Physician(s)

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Describe your functional limitations.* This field is required.Describe how your medical condition limits specific physical, cognitive, or psychological functions relevant to your job duties (e.g. standing, walking, sitting tolerance, mobility, cognitive fatigue, concentration, lifting, travel, attendance).

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Are these limitations:* This field is required.Choose one.

Temporary

Permanent

Episodic/variable

Not sure

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Requested accommodation(s)* This field is required.List the specific accommodation(s) requested (e.g., remote work, modified schedule, ergonomic equipment, duty modification).

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Has a Functional Capacity Evaluation (FCE) or similar assessment been completed?* This field is required.

YESNO

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Medical records you plan to submitCheck all that apply.

Functional Capacity Evaluation (FCE)

VA medical records

Private medical records

Imaging / lab reports

Request letter or email from agency/employer (if available)

Other

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Approximate number of pages you expect to submit* This field is required.Additional fees may apply for extensive record review. Please plan to submit only records relevant to this request; unrelated records may delay review.

Less than 25 pages

25-50 pages

More than 50 pages

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Acknowledgment of Scope* This field is required.

I understand that this service provides an independent medical opinion based on available records.

I understand this is not advocacy, not legal advice, and does not guarantee approval of my accommodation request.

I understand that additional fees may apply for extensive record review.

I understand that this service provides an independent medical opinion only and does not establish a physician–patient relationship or provide medical treatment.

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Select Service Tier Level * This field is required.Please visit our website at nexuslettermd.com for more details.

Level 1 – Nexus Letter Only

Level 2 – Nexus Letter + Medical Records Summary

Level 3 – Nexus Letter + Records Summary + Physician Video Consultation

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Additional information you believe is relevantOptional

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Please type your nameThis will serve as your e-signature.

First Name

Last Name

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Date submitted(Today's date)

Date