Everyone deserves safe access to health care, but we know many people are facing resistance to simple, reasonable requests for Covid accommodations like respirators and air filters cleaners.

So we’re making it easier for you to request accommodations from your primary care doctor, dentist, specialists, or other health care workers, with a fillable PDF form that clearly lays out your requested accommodations and your legal rights to them.

Download our Request for Accommodation in Health Care Facilities PDF today:

  1. Download the PDF to your computer
  2. Open the file
  3. Fill in the fields (skip this step if you prefer to fill in the form by hand)
  4. Save the form
  5. Email it to your health care provider, take the filled-out form to your health care provider’s office
  6. You can also post the form on the door of your hospital room or nursing home
Follow us

Stay up to date on the latest news, information, and resources.