Chronic Condition Verification Form

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A chronic condition verification form is a type of request form sent by an entity to obtain medical information on a person with a long-term illness or disability. The purpose of a chronic condition verification form is to confirm that an individual has a medical condition that may require a special healthcare plan, disability benefits, support services, or other assistance.

Chronic Condition Verification Form

A chronic condition verification form is a type of request form sent by an entity to obtain medical information on a person with a long-term illness or disability. The purpose of a chronic condition verification form is to confirm that an individual has a medical condition that may require a special healthcare plan, disability benefits, support services, or other assistance.

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Last updated November 27th, 2023

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A chronic condition verification form is a type of request form sent by an entity to obtain medical information on a person with a long-term illness or disability. The purpose of a chronic condition verification form is to confirm that an individual has a medical condition that may require a special healthcare plan, disability benefits, support services, or other assistance.

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CHRONIC CONDITION VERIFICATION FORM

Patient Name: [NAME] Sex: ☐ Male ☐ Female
Date of Birth: [MM/DD/YYYY] SSN: [#] Healthcare ID: [#]
Mailing Address: [ADDRESS] Home Phone: [#] Work Phone: [#]

I hereby authorize the release of the requested medical information. 

Signature ________________________ Date: [MM/DD/YYYY]

Requesting Party Information

Name: [NAME]
Mailing Address: [ADDRESS]
Phone: [#] Fax: [#]
Reason for Request: [VERIFICATION REASON]

Chronic Condition

Chronic Illness/Medical Diagnosis/Symptoms: [DESCRIBE CONDITION/SYMPTOMS]

Physician Information

Name: [NAME]
Mailing Address: [ADDRESS]
Phone: [#] Fax: [#]

Signature ________________________ Date: [MM/DD/YYYY]
Print Name: [NAME] Title: [TITLE]

Form Purposes

Insurance

A verification form may be requested when an individual with a chronic condition is making a claim with their insurance company. In other cases, this form is requested by insurance providers to preauthorize treatments and procedures or to renew ongoing medical coverage.

Educational Institutions

When a student has a chronic condition, the school may send a verification form to their physician to confirm the illness. The form may ask for symptoms and other medical information so they can prepare for the student’s periodic absence throughout the school year.

Employment

A verification form is used by some employers to establish an employee’s legitimate disability when they make requests for special assistance, benefits, or other services in the workplace.

Government Agencies / Nonprofit Organizations

Governmental or nonprofit entities may ask for chronic condition verification when someone applies for disability benefits or other financial/medical assistance from social security offices, disability services, or other assistance and support organizations.

Types of Chronic Conditions

For the purposes of special medical plans, school/work absences, and disability services, chronic conditions are medical issues that continually affect the patient over their lifetime. The list below includes a number of chronic conditions that may require specific healthcare plans, benefits, and other support:

  • Arthritis
  • Cardiovascular diseases
  • Chronic respiratory diseases
  • Developmental disability
  • Diabetes
  • Mental illness (including PTSD)
  • Neurological diseases and cognitive impairments