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Attachment U

MARYLAND DEPARTMENT OF HUMAN RESOURCES

FAMILY INVESTMENT ADMINISTRATION

Date Signed Application

Received in

Local Department

MUST BE DATE STAMPED

APPLICATION PART II: Eligibility Determination Document For One Person

PLEASE PRINT ALL ANSWERS

				Do you have
I wish to apply for:		I am currently receiving:		unpaid medical
Cash Assistance	Medical Assistance	Cash Assistance	Medical Assistance: ID#_________	bills now?
Food Stamps	Other, list:_______	Food Stamps	Other, list:____________	YES NO

1. IDENTIFYING INFORMATION

Last Name	First Name	Middle Name	Jr., III, etc.	Maiden/Other Name

What language do you speak?				Do you need an interpreter?			YES	NO
Are you visually impaired		YES NO		Are you hearing impaired?			YES	NO
2. ADDRESS Where do you live?
Number	Street		Apt No.		Floor No.	Telephone Number

City			State		Zip Code + 4	Number where you can be reached
						during the day

3. MAILING ADDRESS (IF DIFFERENT)

Number

Street

Apt. No.

Floor No.

Telephone Number

P.O. Box

City

State

Zip Code + 4

4. PREVIOUS ADDRESSES

Number

Street

City

State

Zip Code + 4

When did you live there?

From

Did you own this home?

YES NO

5. AUTHORIZED REPRESENTATIVE (IF DESIRED)

First Name

Middle Name

Last Name

Jr., III, etc.

Number

Street

City

State

Zip Code + 4

Telephone Number

Relationship to you

Check what you want the representative to do:

Complete interview for you

Cash your check

Receive your notices

Sign your application

Cash your Food Stamps

Receive your Medical Assistance Card

FOR

LDSS Office

Programs Applied For / Receiving

Assistance Unit ID’s

WORKER

Worker’s Name

USE

Client ID

Application/Redetermination Date

ONLY

DHR/FIA CARES 9702 (Revised 10/06)

6. INDIVIUAL INFORMATION Complete the section below.

Last Name

First Name

Middle Name

Jr.,III etc.

Maiden/Other Name

Social Security Number

List Additional Social Security Number

Date of Birth

Sex

Race * (Optional)

Male

Female

Resident of

Marital Status

Due date if pregnant

Number expected

Receiving Prenatal Care?

Maryland

YES

Receiving benefits in another state:

Public Assistance?

YES

Food Stamps?

YES

Medical Assistance? YES NO

U.S. Citizen?

Student?

On Strike?

Disabled or

Medical

Medicare

Medicare#

YES

Incapacitated?

Insurance?

Part A

YES

YES NO

7. MIGRANT WORKER

8. BOARDER If you are a boarder, fill in this sections:

Are you a migrant worker?

Number of Meals per Day

Cost of Meals per Month

YES

9. CITIZENSHIP if you are not a United States citizen, fill in this section

INS Status

Newly Legalized Status Date

Sponsored Alien

Country of Origin

YES NO

US Entry Date

INS Number

10. SCHOOL if you are in school, fill in this section:

Student Status

Educational Level

Highest Grade Completed

Full-time

Elementary

College

Half-time

Secondary

Other, List:_______________

Expected Graduation Date (If in high

Less than half-time

school)

School Name

School Number

School Address

City

State

Zip Code + 4

11. DISABILITY If you are disabled or incapacitated, what is the disability?

12. MEDICAL INSURANCE If you have medical insurance, fill in this section:

Policy Number

Group Number

Policy Holder Name

Relationship to Policy Holder

FOR

WORKER USE

ONLY

Financial Responsibility

Penalty Type

Penalty Date

Special Needs (NEED)

DHR/FIA CARES 9702 (Revised 10/06)

12. MEDICAL INSURANCE (continued)

POLICY HOLDER ADDRESS

Number	Street

City		State		Zip Code + 4		Telephone Number

		INSURANCE COMPANY
Insurance Company Name

Number	Street

City		State		Zip Code + 4			Telephone Number

			UNION
Union Name					Union Local Number

Number	Street

City		State		Zip Code + 4			Telephone Number

13. VETERAN INFORMATION If you are a veteran or a disabled widow or widower, or a disabled child of a deceased veteran, fill in this section:

Veteran’s Name	Relationship to Veteran	Veteran’s Status	Military Service Number

14. MEDICAL EXPENSE

If you are 60 or older, blind or disabled and applying for or receiving Food Stamps, do you have medical bills that you must pay?

YES NO	If Yes, bring in your bills.
15. LIQUID ASSETS Complete for assets as of the 1st day of the month. Check Yes or No for each ASSET TYPE
					AMOUNT	ACCOUNT	FDIC	INSTITUTION
ASSET TYPE		CHECK ONE		OWNER	Balance/value	NUMBER	NUMBER
Cash on Hand		YES	NO		$	N/A	N/A	N/A

Checking Accounts		YES	NO		$

Savings Accounts		YES	NO		$

Credit Union Accounts		YES	NO		$

Trust Funds		YES	NO		$

IRA or Keogh Accounts		YES	NO		$

Stocks, bonds,		YES	NO		$
Certificates, Money
Market Funds, treasury or
Other Notes
Annuities:		YES	NO		$

Other, List:		YES	NO		$

Other, List		YES	NO		$

Other, List		YES	NO		$

Other, List		YES	NO		$

Other, List		YES	NO		$

DHR/FIA CARES 9702 (Revised 10/06)

Lawyer Name

Lawyer Telephone

LIFE INSURANCE AND FUNERAL PLANS If you have any life insurance or pre-paid burial plans or funds, full in this section. List all policies and plans no matter who pays for them.

NAME OF PERSON	ORIGINAL FACE	CURRENT	POLICY NUMBER	LIFE	COMPANY, FUNERAL
WHO PAYS	VALUE OR	CASH	OR ACCOUNT	INSURANCE	HOME OR BANK
	VALUE OF PLAN	VALUE	NUMBER	OR BURIAL	NAME
				PLAN
	$	$

17.REAL PROPERTY If you own property, fill in this section. Include burial plots.

Number

Street

City

State

Zip Code + 4

How Used?

Current Fair Market

Amount Owed Now

Trying to Sell

YES NO

Number Street	City	State	Zip Code + 4

How Used?	Current Fair Market	Amount Owed Now	Trying to Sell
			YES NO

18.OTHER ASSETS If you own other assets not listed, such as antiques, boat, recreational vehicle, coin collections, furs, jewelry, livestock, or stamp collections, fill in this sections:

ASSET TYPE		CURRENT FAIR MARKET VALUE	AMOUNT OWED
	$		$
	$		$

19.POTENTIAL ASSET OR INCOME If you are expecting to receive an accident settlement, trust fund, inheritance or other money or property, full in this section.

Type

Explanation

20.TRANSFER OF ASSETS if you sold, traded or gave any property, motor vehicles, stocks, bonds, cash or other assets in the past 3 years (5 years for a trust), fill in this sections:

Transfer Date	Who Received the Asset?	Type of Assets

Fair Market Value When Transferred

Amount Received

Reason for Transfer

DHR/FIA CARES 9702 (Revised 10/06)

21.INCOME FROM WORKING If you are working now, fill in this section. If not, list the last job held. Include full-time, part-time or temporary work or self-employment, such as owning a business, roomer or boarder income, babysitting, home demonstrations, cleaning houses, etc.

Employer Name

Employer Address- Number

Street

City

State

Zip Code + 4

Telephone

Type of Job

Date Job	Date Job	Reason for	Date Last Pay Received if Job			Gross Wages before deductions per
Began	Ended	Leaving	Ended			Pay Period (include tips,
						commissions)
						$
Hours Per	How Often	If Income from		Self-employment or	Type
Pay Period	Paid?	Boarders, How		Handicapped work
		Many Boarders?		Expenses	Amount		$	$

Employer Name							Federal ID

Employer Address Number

Street

City

State

Zip Code+4

Telephone

Type of Job

Date Job

Began

Date Job

Ended

Reason for Leaving

Date Last Pay Received If Job Ended

Gross Wages before deduction per Pay Period (include tips, commissions)

Hours per Pay Period

How Often Paid?

If Income from Boarders, How Many Boarders?

Self-employment or Handicapped Work Expenses

Type

Amount

22.OTHER INCOME AND BENEFITS Check if you are receiving, have applied for or have been denied any of the following:

	TYPE OF BENEFIT	RECEIVING		AMOUNT	APPLICATION STATUS		APPLICATION
		BENEFITS					OR DENIAL
							DATE
	Alimony	YES	NO	$	Applied for	Denied
	Child Support	YES	NO	$	Applied for	Denied
	Social Security Claim #:	YES	NO	$	Applied for	Denied
	SSI Claim #:	YES	NO	$	Applied for	Denied
	Railroad Retirement Benefits Claim#:	YES	NO	$	Applied for	Denied
	Veteran’s Pension/Benefits	YES	NO	$	Applied for	Denied
	Unemployement Benefits	YES	NO	$	Applied for	Denied
	Worker’s Compensation	YES	NO	$	Applied for	Denied
	Pension or Retirement	YES	NO	$	Applied for	Denied
	Disablility/Sick/Maternity Benefits	YES	NO	$	Applied for	Denied
	Union Benefits	YES	NO	$	Applied for	Denied
	Military Allotment	YES	NO	$	Applied for	Denied
	HUD Section 8 Utility Benefits/Supplements	YES	NO	$	Applied for	Denied
	Money from Friends or Relatives (loans & other)	YES	NO	$	Applied for	Denied
	Money from Rental income	YES	NO	$	Applied for	Denied
	Black Lung Benefits	YES	NO	$	Applied for	Denied
	Lump Sum Amounts	YES	NO	$	Applied for	Denied
	Civil Service Annuity	YES	NO	$	Applied for	Denied
	Public Assistance/State Disability Benefits from	YES	NO	$	Applied for	Denied
	Another State
	Interest or Dividends from Stocks, Bonds,	YES	NO	$	Applied for	Denied
	Savings, or Other Investments
	Other Income (not listed above)	YES	NO	$	Applied for	Denied
	Specify ______________________________

	Other Income (not listed above)	YES	NO	$	Applied for	Denied
	Specify ______________________________

DHR/FIA CARES 9702 (Revised 10/06)						5

23.WORK REGISTRATION/PARTICIPATION FOR FOOD STAMP AND REFUGEE ASSISTANCE ONLY Certain applicants over 16 must register and participate in a work program. The work programs are the Food Stamp Employment and Training Program and the Refugee work Registration Program. You may not have to participant if you have a good reason. You may volunteer if you do not have to participate. Fill in this section.

Wish to		Reason NOT able to participate?
volunteer?
YES	NO

24.SHELTER COSTS Are you paying for any of the following? Complete only if you are applying for Food Stamps

Expenses	Check One		Amount	How	Who	Expenses	Check One		Amount	How	Who Pays?
				Often	Pays?					Often
				Paid?						Paid?
	YES	NO	$			Sewer	YES	NO	$
Rent
	YES	NO	$			Garbage	YES	NO	$
Mortgage
	YES	NO	$			Coop/	YES	NO	$
Electric						Condo Fee
	YES	NO	$			Homeowner	YES	NO	$
Oil						Insurance (if
	YES	NO	$			not included			$
Gas						in mortgage)	YES	NO
Property	YES	NO	$			Other Utility	YES	NO	$
Taxes						Cost, list

	YES	NO	$			Other Utility	YES	NO	$
Telephone						Cost, list

	YES	NO	$			Other Utility	YES	NO	$
Water						Cost, list

Do you live in: Public Housing

Do you receive a Utility Supplement?

Is heat included in the rent?

If heat is not included in the rent, Check the main source of heat:

Section 8 Housing

YES NO

FMHA 515 Housing

Private Housing

Do you pay for lights or cooking? YES NO Check any other source(s) of heat:

Oil	Gas
Electric	Coal
Wood	Kerosene
Propane	Other, list:

If you are sharing any of the costs listed above, fill in this section:

Oil	Gas
Electric	Coal
Wood	Kerosene
Propane	Other, list

TYPE OF EXPENSES	WITH WHOM	TOTAL AMOUNT	AMOUNT OF YOUR
SHARED		OF SHARED EXPENSES	SHARE
	$		$

25. ADDITIONAL INFORMATION

DHR/FIA CARES 9702 (Revised 10/06)

YOUR RIGHTS AND RESPONSIBILITIES

YOU HAVE THE FOLLOWING RIGHTS

RIGHT TO WRITTEN NOTICE – We must always give you a written notice explaining your benefits when we approve your case. We must always give you written notice when we change your benefits, deny or close your case. You have 90 days from the notice date to ask for a hearing. If you ask for a hearing within 10 days, you may be able to keep getting benefits while you wait for the hearing.

RIGHT TO APPEAL - Ask for a hearing if you disagree with the Department’s decision. Your case manager can help you write your appeal. At the hearing, you can speak for yourself or bring a lawyer, friend or relative to speak for you. You may call the Department at 1-800-332-6347 for help to request a hearing.

EQUAL RIGHTS – Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy state we can not discriminate against you because of race, color, national origin, sex, age, or disability. Under the Food Stamp act and USDA policy, we also cannot discriminate against you because of religion or political beliefs.

If you think we have discriminated against you, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, Room

326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TDD). USDA and HHS are equal opportunity providers and employers.

RIGHT TO PRIVACY – You are giving personal information in the application. We use the information to see if you are eligible for benefits. If you do not give information, we may deny your application. You have a right to review, change, or correct any information. We will not show your information or give it to others unless you give us permission or federal and state law allows us to do so.

RIGHT TO CLAIM GOOD CAUSE – If you want Temporary Cash Assistance (TCA), you must help the Department get child support. You may not have to help if it puts you or your family in danger.

RIGHT TO REFUSE HELP – You do not have to accept help from a religious organization if it is against your religious beliefs.

YOU HAVE THE FOLLOWING RESPONSIBILITIES

PROVIDE INFORMATION – You must give true and complete information. You must provide proof of this information. We will keep this information private.

Collecting application information, including the social security number of each household member, is authorized under the Food Stamp Act 1977 as amended, U.S.C. 2001-2036, Social Security Act 1137(F) and 42 U.S.C. 1320b –7 (d).. We use the information to find out if your household is eligible.

We also use the information to see if you meet program rules. We may contact your employer, bank or other party. We may also contact local, state or federal agencies to make sure the information is correct. We can give your information to other federal or state agencies for official use and to law enforcement officers who need it to find persons fleeing to avoid the law.

If you get too much in benefits, we may give the application information, including social security numbers, to federal or state agencies, as well as private claims collections agencies, for action.

Giving information is voluntary. If you do not give us information, including social security numbers, for everyone who wants help; we may deny benefits for each person who does not give a social security number. If you do not have a social security number, we will help you get one.

REPORT CHANGES – You must report all changes within 10 days unless you have a job and are part of the food stamp simplified reporting group and you are not receiving Cash Assistance or Medical Assistance. If you want to know if you are part of this group, ask your case manager. You may tell us about any changes in person, by telephone, or by mail to the Department.

DHR/FIA CARES 9702 (Revised 10/06)

YOUR RIGHTS AND RESPONSIBILITIES

WARNING – WE MAY DENY, LOWER OR STOP YOUR BENEFITS IF YOU GIVE US WRONG INFORMATION OR DO NOT REPORT CHANGES. A JUDGE MAY FINE AND/OR IMPRISON YOU IF YOU DELIBERATELY GIVE WRONG INFORMATION OR DO NOT REPORT CHANGES.

FOOD STAMP PENALTY – Household members shall not

Give false information or withhold information to get or continue to get Food Stamps

Trade or sell Food Stamps, or electronic benefits cards.

Use Food Stamps to buy items not allowed, such as alcohol and tobacco.

Use someone else’s Food Stamp benefits.

Use someone else’s Electronic Benefits Card without authorization

Your food stamps will not increase if your cash assistance case is reduced or closed because you did not follow the rules.

If a household member deliberately breaks the rules, we may bar the person from the Food Stamp Program.

We may bar this person for one year after the first violation.

We may bar this person for two years:

*After the second violation, or

*After the first time a court finds this person guilty of buying illegal drugs with Food Stamps, or

*After the first time a court finds this person guilty of buying guns, bullets, or explosives, with Food Stamps. *After a court finds this person guilty of trafficking food stamp benefits of $500 or more.

A judge can also fine this person up to $250,000, imprison the person for up to 20 years, or both. A judge can also bar this person for an additional 18 months. The person may also have to face further prosecution under other federal laws.

TCA PENALTY – If an assistance unit members is convicted of an Intentional Program Violation (IPV), everyone in

your family will lose their benefits.

The first time, you will lose your benefits for 6 months or until you repay all of the money.

The second time, you will lose your benefits for 12 months or until you repay all of the money.

The third time, you cannot get TCA benefits again.

MEDICAL ASSISTANCE WARNING AND PENALTY – Only use Medical Assistance cards if you are eligible.

Every person convicted of “Medical Assistance Fraud” with a value of $500 or more in money, services, or goods is guilty of a felony, and shall:

1.Pay back money, services or goods; of the value of those services or goods unlawfully received;

2.Be subject to a fine of a no more than $10,000, imprisoned for no longer that five years, or both.

Every person convicted of “Medical Assistance Fraud” with a value of less than $500 in money, services or goods is guilty of a misdemeanor, and shall:

1.Pay back money, service or goods; of the value of those service or goods unlawfully received;

2.Be fined no more than $1,000 and imprisoned for no longer than three years, or both.

DHR/FIA CARES 9702 (Revised 10/06)

YOUR RIGHTS AND RESPONSIBITIES

READ BEFORE SIGNING:

I understand that I can be fined, imprisoned or have my benefits reduced for making false statements or for pretending to be another person.

I also know I can be punished for not reporting changes that may affect my eligibility or benefit amount.

I know the Department can use the application against me in a court or law for fraud prosecution.

I know that failing to report to verify shelter, medical, or dependent care expenses or child support payments is the same as saying I do not want a deduction for the expense I did not verify or report.

I understand that the Department may select my case for a spot check.

I agree to allow someone from the Department to visit me at home. I will help them get all needed proofs from any source.

I agree that Medicare Part B will make payments directly to doctors and medical suppliers.

I give the Department the right to seek payment from private or public health insurance and any liable third party. I understand that must cooperate with the Department in securing such payments. The Department may seek payment without legal action, as long as it does not keep more than amount Medical Assistance paid.

I give the Department the right to inspect, review and copy all medical records for service received through the Medical Assistance Program.

I understand that when a person is deceased who was at least 55 years old when receiving Medical Assistance the state may take money from the estate to repay payments made on behalf of that person. The program may take the money only if there is no surviving spouse, unmarried child younger than 21, or blind or disabled child (married or unmarried) of any age.

SIGNATURE SECTION

I have read or someone has read and explained the entire application to me, I swear or affirm under penalty of perjury that all the information I gave is true, correct, and complete to the best of my ability, behalf and knowledge. I received a copy of my rights and responsibilities. I authorize any person, partnership, corporation, association, or governmental agency that know the facts about my eligibility to give that information to the Department. I also authorize the Department to contact any person, partnership, corporation, association, or governmental agency that has given proof of my eligibility for benefits. I certify, under penalty of perjury, that by signing my name below, all persons for whom I am applying are U.S. citizens or lawfully admitted immigrants.

Signature of Applicant/Recipient	Date

Signature of Witness (If you signed an X)	Date

Signature of Spouse (If Applicable)	Date

Signature of Authorized Representative (If Applicable)

Date

Signature of Case Manager

Date

I withdraw my application for:  Cash Assistance	 Food Stamps	 Medical Assistance
Signature of Applicant, Recipient or Authorized Representative		Date

DHR/FIA CARES 9702 (Revised 10/06)

YOUR RIGHTS AND RESPONSIBLITIES

ASSIGNMENT OF SUPPORT RIGHTS FOR TEMPORARY CASH ASSISTANCE

I assign to the State of Maryland all rights, titles, and interest in support that I may have for myself or for any person receiving TCA.

This includes any overdue support that has been collected.

I agree to send to the State of Maryland any support I receive. If I do not turn over this support, I will have to repay this amount to the State of Maryland. I may also be prosecuted for fraud.

When I am eligible for Medical Assistance:

I assign all rights, title, and interest in medical support and health insurance payments I may have for myself or any person receiving Medical Assistance. This includes overdue medical support or health insurance payments that have not been collected.

I agree to have the child support agency collect medical support payments owed to me and to keep up to the amount of Medical Assistance payments that have been made to me.

I agree give the State of Maryland any medical support or health insurance payments I receive.

I will cooperate to the best of my ability and knowledge with the child support agency while I am receiving TCA and Medical Assistance

If I do not cooperate with the child support agency to the best of my ability and knowledge, I may lose all of my benefits and my case may be closed.

I HAVE READ THESE STATEMENTS OR SOMEONE HAS READ THEM TO ME. I UNDERSTAND WHAT THEY MEAN. BY SIGNING MY NAME BELOW, I AGREE TO FOLLOW WHAT THEY SAY.

Signature

Date

DHR/FIA CARES 9702 (Revised 10/06)

MEDICAL ASSISTANCE PROGRAM

VOCATIONAL, EDUCATIONAL, AND SOCIAL DATA

Department of Social Services

To be completed by applicant and reviewed during interview, with assistance from case manager as necessary.

Name

Social Security #

Alien Residency Date

Customer ID#

Date of Birth

Sex: M___ F___

Alien Status

PART 1: WORK HISTORY

What is the date you last worked? ______/________/______

List all jobs held in the last fifteen years. Begin with your most recent job. To list more jobs, use Part 9: COMMENTS.

Job Title

What You Did

Date

Started

Date

Ended

Hours Per Week

Reason for Leaving

In your usual job did you:	YES	NO
Use machines, tools, or equipment of any kind?	____	____
Use technical knowledge and skills?	____	____
Do any writing, complete reports, etc.?	____	____
Supervise other people	____	____	If yes, how many people?________

Check the number of HOURS you performed the following physical activities in your usual job:

Activity	0	1	2	3	4	5	6	7	8
Bend
Squat
Crawl
Reach
Climb

Activity	0	1	2	3	4	5	6	7	8
Sit
Stand
Walk
Lift
Carry

Check the HEAVIEST weight lifted in your usual job.

___ Less than 10 lbs.

__ 10 lbs.

__25 lbs.

__ 50 lbs.

__ 100 lbs.

__ More than 100 lbs.

Check the weight FREQUENTLY lifted/carried in your usual job.

___ 10 lbs.

___ 25 lbs.

___ 50 lbs.

___ more than 50 lbs.

Part 2: EDUCATION/TRAINING

Can you Speak English?

__YES __ NO

Can you Read English? __ YES __ NO

Can you Write English? __ YES __NO

Circle the highest grade completed 1

Were you in any special education classes during high school? ___ YES

___ NO

Please check and give date received if one applies:

___High School Diploma

___High School Certificate

___GED

Date Received

Attended College From Dates

Degree:

Have you had Vocational, Military, or Job Training?

___ YES

____ NO

Please describe the training:

List type of license or certificate

Date:

DHR/FIA 4204 (revised 7/06)

Part 3: SOCIAL SECURITY DISABILITY/SSI BENEFITS

Have you applied for Social Security Disability and/or SSI benefits				__ YES__ NO
___ I applied for benefits on this date: /		/
	Month	Day	Year
___ My application for SSI/SSDI is still pending
___ My application for SSI/SSDI was denied:			/	/
		Month	Day	Year

___ I intend to file an appeal

___ I have filed an appeal: Please check all that apply and give date filed

___Reconsideration	Date:	/			/
			Month	Day	Year
___Hearing before Administrative Law Judge				Date:			/	/
						Month		Day Year
___Appeals Council	Date:		/		/
		Month		Day	Year

PART 4: MEDICAL

What medical conditions prevent you from working? Please list all conditions. Briefly explain how your conditions keep you from working.

When did your conditions first bother you? Date:		/	/
	Month	Day	Year
PART 5: INFORMATION ABOUT YOUR MEDICAL TREATMENT AND RECORDS

Have you been seen by a doctor/hospital/clinic or anyone else for the illnesses, injuries or conditions that limit your ability to work?

___ YES

____ NO

Have you been seen by a doctor/hospital/clinic or anyone else for emotional or mental health problems that limit your ability to work?

	___ YES	____ NO
Please list your treatment sources for your physical and/or mental conditions. To list more sources, use Part 9: COMMENTS

NAME OF DOCTOR/MCO	ADDRESS	TELEPHONE	DATES & REASON FOR VISIT
			Starting Date: _____________________
			Last Seen: ________________________
			Reason:__________________________

			Starting Date: _____________________
			Last Seen: ________________________
			Reason:__________________________

			Starting Date: _____________________
			Last Seen: ________________________
			Reason:__________________________

DHR/FIA 4204 (revised 7/06)

NAME OF	ADDRESS	TELEPHONE#	DATES & REASON FOR VISIT
THERAPIST/COUNSELOR
			Starting Date:_____________________
			Last Seen:________________________
			Reason:__________________________

			Starting Date:_____________________
			Last Seen:________________________
			Reason:__________________________

			Starting Date:_____________________
			Last Seen:________________________
			Reason:__________________________

NAME OF	ADDRESS	TELEPHONE#	DATES & REASON FOR VISIT
HOSPITAL/CLINIC
			Admission:_____________________
			Discharge:________________________
			Reason:__________________________

			Admission:_____________________
			Discharge:________________________
			Reason:__________________________

			Admission:_____________________
			Discharge:________________________
			Reason:__________________________

MEDICATIONS: List all prescription and nonprescription medications that you now take, and their side effects, which may keep

you from working, e.g. drowsiness and dizziness, etc. To list additional medications, use Part 9: COMMENTS

NAME OF MEDICATION

REASON FOR MEDICATION

SIDE EFFECTS

PART 6: BEHAVIORAL HEALTH

Do you have any of the following thoughts or feelings?

Thought/Feeling

YES NO

Feel sad a lot of the time

Have problems sleeping (too much or too little)

Loss of interest in activities I usually like

Feel guilty or worthless

Changes in appetite (eat too much or to little)

Feel or think people are trying to hurt me

Loss of energy

Much more energy than usual

Thought/Feeling

YES NO

Have panic attacks

Have problems concentrating or thinking

Hear voices when no one is there

See things that others don’t see

Feel nervous or worried all the time

Think of hurting myself

Think of hurting others

Feel hopeless or desperate

DHR/FIA 4204 (revised 7/06)

PART 7: INFORMATION ABOUT YOUR ACTIVITIES

How often do you have DIFFICULTY doing the following? (Check: always, often, seldom, or never after each activity.) Please check, if pain is associated with or affects your ability to engage in an activity)

ACTIVITY ALWAYS OFTEN SELDOM NEVER AFFECTED BY PAIN

Sitting

Standing

Walking

Bending

Lifting

ACTIVITY ALWAYS OFTEN SELDOM NEVER AFFECTED BY PAIN

Grasping

Reaching

Pushing

Pulling

Taking care of yourself

Do you have any problems bathing? __ YES __ NO If, yes, please explain:

Do you have any problems dressing?

__ YES__ NO If yes, please explain:

Describe any changes in taking care of yourself since you became unable to work:

Taking care of where you live

Do you live in an apartment ___ or house ___? Who lives with you?

Do you clean house, do odd jobs/chores around the house/yard? ___ YES___ NO

If yes, what do you do?

How often do you do these things?

How long does it take you to do these things?

Do you need help? __ YES __ NO If yes, please explain:

Do you need to stop and rest? __ YES

__NO

If yes, explain why.

Describe any changes in taking care of your household since you became unable to work:

Cooking

Do you prepare your own meals? __ YES

__ NO If yes, which meals? __Breakfast __ Lunch __ Dinner

What kind of food do you usually prepare?

How often do you cook your own meals?

Do you need help? __ YES

__ NO If yes, please explain:

Do you need to stop and rest? __YES

__ NO How often do you need to rest?

Describe any changes in your cooking habits since you became unable to work:

Shopping

Do you go shopping? __ YES

__ NO If yes, what kind of shopping do you do? (Groceries, clothing, etc):

How often do you shop?

Do you need help shopping? __YES

___ NO

If yes, please explain:

Do you handle your own money? __ YES __ NO If no, please explain:

Describe any changes in your shopping habits since you became unable to work:

Going out in public

How do you get to places you need to go?

Can you drive? __ YES __NO If no, please explain:

How long can you drive without stopping and resting?

Do you need help when you go out? __ YES__ NO If yes, please explain:

Do you have problems walking or climbing stairs? __YES

__NO If yes please explain:

Describe any changes in going out in public since you became unable to work:

DHR/FIA 4204 (revised 7/06)

Hobbies/Activities/Pastimes

What do you do in your spare time? (For example: reading, writing, gardening, sewing, watching TV)

How often do you do these things?

Do you need to stop and rest? __ YES __ NO If yes, please explain:

How often do you need to stop and rest?

Describe any changes in your hobbies and pastimes since you became unable to work:

Social Relationships

Do you go and visit people? __ YES__ NO If yes, how often?How long? If no, please explain why you do not go out and visit with people:

Do you talk on the phone with other people __ YES__ NO If yes, how often?			How long?
Describe any changes in your social relationships since you became unable to work:

Other

Do you have any problems remembering? __ YES__ NO If yes, please explain:

Do you have any problems concentrating? __ YES__ NO If yes, please explain:

Do you have any problems understanding? __ YES__ NO If yes, please explain:

Do have problems listening? __ YES __ NO If yes, please explain:

Do have problems getting along with others? __ YES__ NO If yes, please explain:

(Only complete the next section if you experience pain)

Part 8: INFORMATION ABOUT YOUR PAIN. Use Part 9: COMMENTS if more space is needed. Describe your pain – Please include where the pain is located and if it spreads to other areas of your body.

Describe the kind of pain (dull, burning, aching, sticking, sharp, shooting, etc) On a scale of 1-10 how severe is it. (10 is the worst)

Describe how pain affects your activities, including your ability to concentrate and remember.

How often do you experience pain? Is it constant or does it occur only with certain activities?

Is it worse in the morning, afternoon or evening?

DHR/FIA 4204 (revised 7/06)

How long does the pain last?

What makes your pain worse? (lifting, standing, cold weather, etc.)

Describe any treatments (medications, hot baths, therapy, exercise, etc.) used to relieve your pain. How well do they work? How often do you use them?

Describe the activities you have had to restrict or stop because of pain.

Part 9: COMMENTS

Use this space to provide additional information.

	/		/
Applicant’s Signature		Date			Printed Name of Applicant

FOR OFFICE USE ONLY

Comments by Case Manager: Please note any observations of the claimant’s behavior, appearance, degree of limitations, etc.

_______________________ _____/_____/________		_________________________	_________________________
Case Manager’s Signature	Date	Printed Name of Case Manager	Case Manager’s Phone #
______________________ _____/_____/________		__________________________	_________________________
Supervisor’s Signature	Date	Printed Name of Supervisor	Supervisor’s Phone #

DHR/FIA 4204 (revised 7/06)

Department of Social Services

MEDICAL REPORT FORM 402B

District:

Worker:

Phone#:

Date:

Client ID:

The information provided on this form may be used to determine eligibility for federal and state programs using Social Security disability criteria.

Please Print or Type

A. Patient Information:

Name of Patient:

Address:

Phone:

Date of Birth:

SSN#

Physician’s Name:

Address:

Phone:

Specialty:

Dates of Examination

First Visit:

Last Visit:

Presenting Symptoms:

Height:

Weight:

BP:

Muscle Strength (1/5 to 5/5): UE

B.Diagnosis: (You must attach progress notes or any other general records currently available)

ICD-9-CM		Onset Date
ICD-9-CM		Onset Date
ICD-9-CM		Onset Date
ICD-9-CM		Onset Date
ICD-9-CM		Onset Date

HIV/AIDS INFECTION: Opportunistic and Indicator Disease (Please check all those that apply).

฀Bacterial Infections ฀ HIV Wasting ฀ Viral Infections ฀ Diarrhea ฀ Protozoan or Helminthic Infections

฀ Neurological Abormalities ฀ Fungal Infections		฀ Other, specify
CD4 Count		Viral Load

Diagnostic Tests Performed: (To receive payment for laboratory tests or other diagnostic evaluations, including psychiatric and psychological evaluations, you must attach results or provide the date when results will be available.)

Treatment and Response: Include past treatment and response, if known, and current treatment and response. Please

include therapy and recommendations:

DHR/FIA 402-B (Revised 3/07)

C.MEDICATIONS: Include all prescription and nonprescription medications currently being taken, and side effects that may have implications for working, e.g. drowsiness and dizziness, etc.

Name of Medication

Reason For Medication

Side Effects

D.Referral to Specialist Recommended: Please explain reasons for referral

E.Physical Limitations:

In terms of the patient’s ability to perform during an 8-hour workday with normal breaks, the patient can:

	No
Activity	Restrictions	Never	1 hr	2 hrs	3 hrs	4 hrs	5 hrs	6 hrs	7 hrs	8 hrs
Sit
Stand
Walk
Climb
Bend
Squat
Reach
Crawl

Check the HEAVIEST weight the patient can lift/carry.

฀Less than 10 lbs. ฀ 10 lbs. ฀ 20 lbs. ฀ 25 lbs. ฀ 50 lbs. ฀ 100 lbs. ฀ More than 100 lbs. Check the weight the patient can lift/carry FREQUENTLY.

฀10 lbs.฀ 25 lbs.฀ 50 lbs.฀ More than 50 lbs.

The patient can be exposed to:

Environmental
Conditions	Never	Occasionally	Frequently
Extreme Cold
Extreme Heat
Humidity
Chemicals
Dust
Fumes/Odor
Noise
Height

Describe how these environmental factors limit the patient’s activities:

The patient can use hands for repetitive action such as:

Hand Action	Yes	No
Simple Grasping
Pushing
Fine Manipulation

DHR/FIA 402-B (Revised 3/07)

Visual Limitations: Visual Field: OD___________OS__________VA__________

(after corrections): OD___________OS__________VA__________

Hearing Limitations	฀ Yes	฀ No	฀ Minimal	฀ Moderate	฀ Extreme
Speaking Limitations	฀ Yes	฀ No	฀ Minimal	฀ Moderate	฀ Extreme
Is substance abuse present?			฀Yes	฀ No
Would the patient’s current condition exist in the absence of substance abuse?
		฀ Yes	฀ No

F. Mental Status Information:

Does the patient suffer from mental illness? ฀ Yes ฀ No If yes, complete section F.

If no, go directly to section G.

Please provide all five axes of a DSM-IV diagnosis:

Axis I

Axis II

Axis III

Axis IV

Axis V	GAF score: current	Highest level in the past year

Cognitive testing (list tests performed with results) VIQ		_PIQ	FSIQ

Please check the appropriate degree of limitation for the following:

Degree of Limitation is defined as “None,” “Mild,” “Moderate,” “Marked” and “Extreme.”

Moderate refers to an impairment or combination of impairments that produce symptoms that have an impact on one’s

ability to function independently, appropriately and effectively on a sustained basis.

Marked refers to an impairment or combination of impairments that produce symptoms that seriously interfere with one’s ability to function independently, appropriately and effectively on a sustained basis. Extreme is defined as continuous and severe.

FUNCTIONAL LIMITATIONS				DEGREE OF LIMITATION
Restriction of activities		None	Mild	Moderate	Marked Extreme
of daily living		฀	฀	฀	฀	฀
Difficulties in maintaining		None	Mild	Moderate	Marked Extreme
social functioning		฀	฀	฀	฀	฀
Difficulties in			None	Seldom Often	FrequentConstant
maintaining concentration,		฀	฀	฀	฀	฀
		persistence or pace
Episodes of		None	Once	Repeated		Continual
decompensation, each of				or Twice(three or more)
extended duration	฀	฀		฀	฀

DHR/FIA 402-B (Revised 3/07)

G. Evaluation of Medical Condition:

Based upon your evaluation is your patient’s medical condition expected to last at least 12 months?

Yes ฀ No ฀

Please give date of onset and the length of time the patient’s medical condition is expected to last or has lasted.

/ To ___/

___/ ___/

month day

year

month day

year

Is the patient’s medical condition expected to result in death?

Yes ฀

No ฀

Does the patient’s medical condition prevent him or her from working in any employment?

Yes ฀

No ฀

If yes, please give the duration.

/To

month

day

year

month

day

year

H. Additional Comments:

Signature:

Print Name:

Title:Telephone:

License:

MA Provider#:

Date:

DHR/FIA 402-B (Revised 3-07)

Question	Answer
Form Name	Dhr Fia Cares 9702 Form
Form Length	20 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min
Other names	HHS, 402-B, MARYLAND, ICD-9-CM

Dhr Fia Cares 9702 Form – Fill Out and Use This PDF

Dhr Fia Cares 9702 Form PDF Details

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