Healthcare Provider Form Verifying Special Needs
2. Mobility Assessment Supplement
American Board of Cardiovascular Medicine, Inc.,
Healthcare Provider Form - To be completed by your physician or healthcare provider.
Patient’s Full Name: ___________________________________
Patient’s Date of Birth: ___________________________________
Patient’s Telephone # ___________________________________
Patient’s Email: ___________________________________
Purpose of this Form:
The American Board of Cardiovascular Medicine, Inc., a private, non-profit organization that develops standardized certification examinations in cardiology. The examinations are used by jurisdictions across the country to help evaluate the qualifications of individuals who are seeking to become Board certified professionals in the field of cardiology and/or electrocardiography.
The purpose of this form is to obtain information that will be relied upon by ABCM in determining whether an exam candidate needs testing accommodations because he or she has a physical or mental impairment that rises to the level of a disability. Accommodations are intended to provide impartiality and accessibility to ABCM’s Board Certification Examinations. Given the important role that certification exams play in protecting the health and safety of the public, accommodations are warranted only when a candidate provides reasonable documentation from a qualified professional who has diagnosed the candidate as having a physical or mental impairment that substantially limits the candidate’s ability to perform one or more major life activities that are relevant when taking an examination.
Instructions:
Please complete this form in a legible manner, sign it, and return it to the candidate along with any test results, evaluation reports, or other documentation prepared as part of your examination and evaluation of the candidate that you believe is necessary to support the candidate’s accommodation request(s). The candidate will provide the form and other documentation (if any) to ABCM for review.
MOBILITY ASSESSMENT SUPPLEMENT
((Print out and have completed by qualified healthcare provider – scan and upload into your application for special needs accommodations.)
)
1. Is the patient able to climb or descend stairs? (Check one)
☐ Yes ☐ No
2. Does the patient use an assistive mobility device, personal attendant, or service animal? If so, please identify.
3. Does the patient have a current need for any of the items listed below? (Check all that apply)
☐ Adjustable chair ☐ Sit/stand desk ☐ Podium
☐ Other (please specify below)
By signing below, I am verifying that (1) the diagnosis(es) and supporting information provided are accurate; and (2) I am a qualified professional who is licensed and properly credentialed to diagnose and treat the stated conditions.
Healthcare Provider Signature: _____________________________ Date: ________
Healthcare Provider Form - To be completed by your physician or healthcare provider.
Patient’s Full Name: ___________________________________
Patient’s Date of Birth: ___________________________________
Patient’s Telephone # ___________________________________
Patient’s Email: ___________________________________
Purpose of this Form:
The American Board of Cardiovascular Medicine, Inc., a private, non-profit organization that develops standardized certification examinations in cardiology. The examinations are used by jurisdictions across the country to help evaluate the qualifications of individuals who are seeking to become Board certified professionals in the field of cardiology and/or electrocardiography.
The purpose of this form is to obtain information that will be relied upon by ABCM in determining whether an exam candidate needs testing accommodations because he or she has a physical or mental impairment that rises to the level of a disability. Accommodations are intended to provide impartiality and accessibility to ABCM’s Board Certification Examinations. Given the important role that certification exams play in protecting the health and safety of the public, accommodations are warranted only when a candidate provides reasonable documentation from a qualified professional who has diagnosed the candidate as having a physical or mental impairment that substantially limits the candidate’s ability to perform one or more major life activities that are relevant when taking an examination.
Instructions:
Please complete this form in a legible manner, sign it, and return it to the candidate along with any test results, evaluation reports, or other documentation prepared as part of your examination and evaluation of the candidate that you believe is necessary to support the candidate’s accommodation request(s). The candidate will provide the form and other documentation (if any) to ABCM for review.
MOBILITY ASSESSMENT SUPPLEMENT
((Print out and have completed by qualified healthcare provider – scan and upload into your application for special needs accommodations.)
)
1. Is the patient able to climb or descend stairs? (Check one)
☐ Yes ☐ No
2. Does the patient use an assistive mobility device, personal attendant, or service animal? If so, please identify.
3. Does the patient have a current need for any of the items listed below? (Check all that apply)
☐ Adjustable chair ☐ Sit/stand desk ☐ Podium
☐ Other (please specify below)
By signing below, I am verifying that (1) the diagnosis(es) and supporting information provided are accurate; and (2) I am a qualified professional who is licensed and properly credentialed to diagnose and treat the stated conditions.
Healthcare Provider Signature: _____________________________ Date: ________
