Every year, individuals in the United States have to file their taxes. In order to do so, they need to fill out a tax form. The most common tax form is the 1040. There are other forms that people may have to file as well, such as the 1041, 1065, and 1120. One of these forms is the Dss 3122 Form. This form is used by individuals who receive distributions from DISC or former DISC arrangements. If you receive distributions from a DISC or former DISC arrangement, you will need to file the Dss 3122 Form. Let's take a closer look at this form and what it entails.
| Question | Answer |
|---|---|
| Form Name | Dss 3122 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | dss 3122 form medical evaluation adult home, 3122 form adult home, substitute for dss form dss 3122 revised 6 96, medical evaluation 6 96 substitue for dss 3122 |
STATEMENT OF PURPOSE
Adult Residential Care Programs provide 24 hour residential care settings for dependent adults. They are not medical facilities. Persons in need of constant medical care and supervision should not be admitted or retained in an adult residential care facility because such a facility lacks the staff and expertise to provide needed services. Persons who, by reason of age and or physical and/or mental limitations, are in need of assistance with the basic activities of daily living, can be cared for in adult residential care settings.
The information solicited in this medical evaluation will assist you, the individual, and the operator of an adult residential care facility in determining the level of care needed to assure the health, safety and
MEDICAL EVALUATION
(Resident)
NAME
ADDRESS
SEX |
DATE OF BIRTH |
EXAMINATION DATE |
MF
SECTION I: MEDICAL HISTORY
PRIMARY DIAGNOSIS
RECENT SURGERY (type of procedure and date)
RECENT ACUTE ILLNESS (type and date)
CHRONIC ILLNESS, PHYSICAL OR MENTAL LIMITATIONS
SPECIAL DIET
WEIGHT (include opinion regarding overweight, etc.)
BLOOD PRESSURE
ACTIVITY RESTRICTIONS
WEIGHT BEARING (full, partial, none)
REQUIRED PERIODIC OR INTERMITTANT NURSING CARE, AND/OR MEDICAL EXAMINATIONS, DOCTORS’ VISITS, OR SKILLED OBSERVATION OF SYMPTOMS:
SECTION II: MEDICATIONS NEEDED
TYPE, FREQUENCY, AND DOSAGE
SECTION III: OBSERVATION OF INDIVIDUAL
yes |
no |
Is the individual capable of |
yes |
no |
Bedfast – Unable to transfer |
|
|
Required medications? |
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|
|
yes |
no |
Ambulatory – Without assistance |
yes |
no |
Incontinent (describe) |
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yes |
no |
Ambulatory – With assistance |
yes |
no |
Habituated or addicted to alcohol or other substance |
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|
yes |
no |
Chairfast – Able to transfer |
yes |
no |
If yes, is the individual a danger to himself or others |
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yes |
no |
Chairfast – Unable to transfer |
yes |
no |
Free of communicable disease |
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yes |
no |
Bedfast – Able to transfer |
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SECTION IV:
In your opinion does the individual need the support and services available in and adult residential care setting? |
(please describe fully) |
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Does the individual require placement in a skilled nursing or health related facility? (give reasons) |
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PHYSICIANS SIGNATURE |
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DATE |
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