H1836 A Form PDF Details

Listed below are some specifics about h1836 a form. It is going to provide you with the projected time it would require you to fill out the form and several extra details.

QuestionAnswer
Form NameH1836 A Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 1836a, 1836 a, texas form 1836 a, hhsc form 1836a printable

Form Preview Example

Medical Release/Physician's Statement

Form H1836-A

March 2015-E

Section I – To Be Completed By Staff

Name of Patient

Date of Birth

Social Security No.

 

 

 

Case Name (caregiver)

Case No.

Patient's Usual Job

 

 

 

Health and Human Services Commission (HHSC) Office Address

HHSC Mail Code

HHSC Fax No.

 

 

 

Section II – To Be Completed By Physician

The patient named above has applied for benefits with our agency. Federal and state regulations require that persons receiving benefits work or participate in activities to prepare them for work unless they are physically or mentally incapable of working. This patient claims that disability. Please complete the appropriate parts. After you complete the form, you may give it to the person or mail it to HHSC at the address in Section I.

Part A – Personal Disability

To what extent is the individual able to work or participate in activities to prepare for work? Please check one of the following boxes:

1. The individual is able to work, or participate in activities to prepare for work, without restrictions:

a. Full time (40 hours/week)

 

b. Part time at

hours/week

2. The individual is able to work, or participate in activities to prepare for work, with restrictions: (Please complete Part B and C)

a. Full time (40 hours/week)

 

b. Part time at

hours/week

3. The individual is unable to work, or participate in activities to prepare for work, at all: (Please complete Part C)

a. The disability is permanent.

b. The disability is not permanent and is expected to last more than 6 months.

c. The disability is not permanent and is expected to last 6 months or less.

Part B – Activity Restrictions

What can this individual do now? Check the appropriate boxes that are applicable during a workday:

Maximum Hours per Workday

2

4

6

8 Other

Sitting

Standing

Walking

Climbing stairs/ladders

Kneeling/Squatting

Bending/Stooping

Pushing/Pulling

Keyboarding

Lifting/Carrying

Other (please describe)

The individual may not lift/carry objects more than Ibs. for more than hours per day.

Individuals with employment limitations may still be assigned to complete community work in an office environment with little physical strain or demand (answering phones, filing while seated, etc.) Others may be assigned to complete employment-related activities in a classroom

setting. In your opinion, can this individual participate in activities of this nature?

Yes

No

Any other remarks, recommendations or restrictions?

Form H1836-A

 

 

 

 

Page 2 / 03-2015-E

 

 

 

 

 

Part C – Diagnosis

 

 

 

 

Primary Disabling Diagnosis

 

 

Secondary Disabling Diagnosis

 

 

 

 

 

 

Comments

 

 

 

 

 

 

 

 

Name of Physician (please type or print)

Signature – Physician

Date

 

 

 

 

Physicians License No.

Office Address (Street or P.O. Box, City, State and ZIP)

Area Code and Phone No.

 

 

 

 

 

Section III – To Be Completed By Patient or Patient's Personal Representative

Authorization to Release Medical Information

Patient's Name:

HHSC is requesting verification of the medical condition that prevents you from participating in the employment services program. When you sign this authorization, you are giving HHSC permission to contact your doctors, medical facilities or other health care providers to request copies of your health information as indicated below. You do not have to sign this form to be eligible for TANF, SNAP, or Medicaid. However, you must sign this form if you want to be eligible for an exemption from the employment services program.

I authorize

 

to complete Form H1836-A, Medical Release/Physician's Statement, and

 

 

 

 

Doctor, Medical Facilities or other Health Care Providers

release the information to HHSC and the Texas Workforce Commission for purposes of verifying the medical condition that prevents me from

participating fully in the employment services program. This authorization expires on

.

 

 

 

 

 

 

 

 

 

 

 

 

 

Client or Personal Representative's Signature

 

 

 

Date

If you are signing for the client, please describe your authority to act for the client:

 

 

 

 

Note: If the person requesting the release of case information cannot sign his/her name, two witnesses to his/her mark (X) must sign below:

Witness

Date

Witness

Date

Notice to Client

HHSC, as receiver of this information, will protect your personal health information in accordance with federal and state privacy regulations. If you authorize release of your health information to other parties, it may no longer be protected by privacy regulations.

You can withdraw permission you have given your doctor or health care provider to use or disclose health information that identifies you, unless they have already taken action based on your permission. You must withdraw your permission in writing.

How to Edit H1836 A Form Online for Free

It is possible to prepare the 1836a hhsc form with our PDF editor. These steps may help you easily prepare your document.

Step 1: Search for the button "Get Form Here" on this website and hit it.

Step 2: Once you have entered the 1836a hhsc editing page you can discover each of the actions you may conduct regarding your file from the upper menu.

Fill in the 1836a hhsc PDF and provide the details for every single section:

stage 1 to writing texas form 1836 a

The application will require you to complete the b The disability is not permanent, c The disability is not permanent, Part B Activity Restrictions, What can this individual do now, Maximum Hours per Workday, Other, Sitting, Standing, Walking, Climbing stairsladders, KneelingSquatting, BendingStooping, PushingPulling, Keyboarding, and LiftingCarrying field.

Filling in texas form 1836 a stage 2

In the Primary Disabling Diagnosis, Comments, Secondary Disabling Diagnosis, Name of Physician please type or, Signature Physician, Date, Physicians License No, Office Address Street or PO Box, Area Code and Phone No, Section III To Be Completed By, Authorization to Release Medical, Patients Name, HHSC is requesting verification of, I authorize, and to complete Form HA Medical part, point out the crucial details.

Finishing texas form 1836 a stage 3

As part of part If you are signing for the client, Note If the person requesting the, Witness, Witness, Notice to Client, Date, Date, HHSC as receiver of this, and You can withdraw permission you, state the rights and obligations.

Filling out texas form 1836 a part 4

Step 3: As you select the Done button, your prepared file can be simply transferred to any kind of your gadgets or to email stated by you.

Step 4: You could make copies of your file toavoid any kind of possible future troubles. Don't worry, we don't disclose or monitor your data.

Watch H1836 A Form Video Instruction

H1836 A Form isn’t the one you’re looking for?

Related Documents

  • Guard Split

    "... Form ng 594 20101123 Ef Annex Dd Form Army National Guard Split Training Option The proponent agency for split training is arn HRH. This prescribing directive is an arn fy privacy act statement authority title ..."

  • Guardianship Of Minors Arizona

    "... Superior court of arizona, maricopa County all rights reserved gt5284 guardianship minors temporary emergency orders form and instructions ..."

  • Gujarat Commercial Tax Form 403

    "... For registered dealers of Gujarat, log on towww commercial tax.gujarat.gov. You will find the link called services. Next you can enter the quantity required for 403 forms. Click the link to access the general menu. ..."

  • H Form 5500

    "... Schedule form 5500 Department of Treasury Internal Revenue Service Department of Labor Pension Benefit Security Administration Financial Information This schedule must be filed under Section 104 of the Employee Retirement Income Security Act of 1974 ..."

Please rate H1836 A Form

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .