Eaedc Medical Report Form – Fill Out and Use This PDF

Department of Transitional Assistance (DTA) and Disability Evaluation Services

(DES) Medical Records Release Form

Sign this form to let your medical and mental health care provider share information with UMASS/Disability Evaluation Services (DES).

HOW TO FILL OUT THIS FORM

Your medical and mental health care provider will only send medical records to UMASS/Disability Evaluation Services if you fill out the form right. Follow these steps:

1.Fill out this Medical Records Release Form before you give the EAEDC Medical Report to your medical and mental health care provider. A medical and mental health care provider is a doctor, nurse, psychologist, psychiatrist, therapist, nurse practitioner, physical therapist, chiropractor, hospital, health center, clinic or other medical or mental health provider.

2.Fill out every section of the Medical Records Release Form. DES can only get your medical information if you fill out every section. DES will decide your case without the information if DES cannot get it.

3.Sign and date the Medical Records Release Form with a pen. Do not sign with a pencil. Sign the form yourself. You cannot use a copy or stamp of your signature.

SECTION I

Your Name and Address

SECTION II

Health Care Provider’s Name and Address

Name of doctor, nurse, psychologist, psychiatrist, therapist, nurse practitioner, physical therapist, chiropractor, hospital, health center, clinic or other medical or mental health provider.

Street address:

(continued on back) 

SECTION III

I allow the medical and mental health care provider listed in Section II to share with DTA and Disability Evaluation Services (DES):

my medical records;

other information about my time in a hospital;

other information about any of my medical care.

I allow the medical and mental health care provider to share all information about my health. This includes information about:

my mental health;

my AIDS/HIV status;

drug and alcohol abuse;

how my health problems affect my ability to work;

how my health problems affect what I do every day.

 Check here if you do NOT allow the medical and mental health care provider to share your AIDS/HIV status:

SECTION IV

I understand that I can cancel this permission at any time. I can cancel this permission by sending a letter to my medical and mental health care provider. I understand that this permission ends six months from the date I sign this Medical Records Release Form, if I do not cancel it before then.

I understand that my medical and mental health care provider may send information to DTA and DES before I cancel my permission. I understand that my medical and mental health care provider cannot get the information back after sending it.

I understand that it is my choice to let my medical and mental health care provider share medical information with DTA and DES. I do not have to give permission. I also understand that DTA and DES will decide about my disability without the information if I do not let my medical and mental health care provider share it.

SECTION V

If the person signing this form has legal authority to act for the applicant/client (such as a legal guardian), give us the following information:

Signature of person completing this form:

What kind of authority do you have to sign for the applicant/client?

Medical Standards

You may reference the Department's Medical Standards at 106 CMR 320.200 or at:

http://www.mass.gov/Eeohhs2/docs/dta/g_reg_320.pdf

Check the standards that apply to this patient's impairment(s):

Part I – Medical Information

IA. Physical Examination - Please include both normal and abnormal findings. (For mental health or cognitive conditions only, skip to Part II.)

Medical history - Include hospitalizations within the past five years. (List facilities, dates and reasons for admission(s):

IA. Physical Examination - Please include both normal and abnormal findings. (For mental health or cognitive conditions only, skip to Part II.)

General appearance:

HEENT:

Cardiovascular system:

Lungs:

Abdomen:

Musculoskeletal exam (Please include range

of motion of affected joints.):

Neurological system

Reflexes:

Motor Strength:

Sensation (light touch, pin prick, vibration and position):

Cranial Nerves:

Cerebellar function (include observed ambulation):

Mental status (i.e., oriented X3, confused, etc.)

Skin:

Additional findings not noted above (i.e. lab findings, x-rays, MRI’s, referrals with dates):

Is the patient’s condition chronic?  no  yes

If the patient’s condition is chronic, is improvement expected?  no  yes

If improvement is expected, what is the year and month that improvement is expected? _____________

Additional comments:

EAEDC-Med Rpt (Rev. 10/2014)

I B. Physical Examination -Assessment and Plan

Which of the above, if any, is a result of accident or injury?

If applicable, please give a general description:

Part II – Mental Health and Cognitive Information

IIA. Mental Health and Cognitive Examination Please include both normal and abnormal findings.

(If no mental health or cognitive conditions, skip to Part III.)

(Must be within 30 days of this report being completed.)

Patient complains of:

History- Include hospitalizations within the past five years. List facilities, dates and reasons for admission(s).

Current clinical signs and symptoms (i.e., sleep disturbance, anhedonia, panic attacks, flashbacks, nightmares, etc.):

Appearance/attitude/behavior:

Orientation (person, date, place):

Mood and affect:

Speech (pressured, paucity of speech, etc.):

Thought process (dissociation, blocking, flight of ideas, etc.):

Thought content (phobias, obsessions, delusions, ideas of reference, etc):

Perceptions (i.e., hallucinations):

Cognition (level of intellectual function, ability to concentrate, ability to learn):

Additional comments:

Which of the above, if any, is a result of accident or injury?

If applicable, please give a general description:

Part III – Additional Impairments

III. Additional Impairments

List any other impairment(s) that may affect the patient's ability to work. List the impairment(s) and any resulting limitations in functioning. If you know the medical and mental health care provider who diagnosed or treated the patient for it, provide the medical and mental health care provider’s name, address and telephone number.

Part IV – Effect on Activities of Daily Living

IV. In as much as you know, does the patient’s medical, mental health, and/or cognitive condition(s) impact

ability to perform daily activities such as: