The EAEDC Medical Report must be signed by a Competent Medical Authority.
Clinical findings: the EAEDC Medical Report must include an objective report of clinical findings and current functioning.
Exam date: the date of exam must be within 30 days of this report being completed.
Release form: fill out the Medical Records Release Form before you give the EAEDC Medical Report to your medical and mental health care provider.
Signing: sign and date the Medical Records Release Form with a pen; you cannot use a copy or stamp of your signature.
Questions: call UMASS/Disability Evaluation Services (DES) at 1-800-888-3420 with questions you may have regarding the completion of this report.
| Question | Answer |
|---|---|
| Form Name | EAEDC-Med Rpt 04-012-0319-05 |
| Form Length | 11 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 33 min |
| Edition | Rev 3/2019 |
| Where to send | This report must be completed in its entirety, signed and returned to the patient or mailed to DTA Document Processing Center, PO Box 4406, Taunton MA 02780-0420, or fax to (617) 887-8765 |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | EAEDC-Med Rpt, 04-012-0319-05, EAEDC Medical Report, EAEDC form, DTA disability form |
| Official source | EAEDC-Med Rpt 04-012-0319-05 (Rev 3/2019), Massachusetts Department of Transitional Assistance |
Eaedc Medical Report Form isn’t the one you’re looking for?