EAEDC-Med Rpt 04-012-0319-05: Massachusetts EAEDC Medical Report

Under PATIENT INFORMATION, fill in Last Name, First Name, Date of Birth, Social Security Number, Address (Street, City, State, Zip Code) and Telephone Number.

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

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.

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.

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:

I understand that I can cancel this permission at any time. You can cancel this permission by sending a letter to your medical and mental health care provider.

This permission ends six months from the date you sign this Medical Records Release Form, if you do not cancel it before then.

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 V Signature of applicant/client: Date: If the person signing this form has legal authority to act for the applicant/client (such as a legal guardian), fill in Signature of person completing this form, Printed name, Date and What kind of authority do you have to sign for the applicant/client.

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.)

In Part I, the Date of exam must be within 30 days of this report being completed.

In Part I, fill in Patient complains of and, under Medical history, include hospitalizations within the past five years. List facilities, dates and reasons for admission(s).

Fill in Temperature, Blood Pressure, Height, Weight, Pulse and Respiratory Rate.

Under Musculoskeletal exam, 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.)

Fill in Skin and Additional findings not noted in Part I (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?

In I B. Physical Examination -Assessment and Plan, for each diagnosis: Diagnosis, Onset Date, If known, date of diagnosis, Anticipated duration, List of Medications and Treatment Plan. Fill in which diagnosis, if any, is a result of accident or injury. If applicable, please give a general description.

Part II - Mental Health and Cognitive Information. II A. Mental Health and Cognitive Examination: Please include both normal and abnormal findings. (If no mental health or cognitive conditions, skip to Part III.)

In Part II, the Date of exam must be within 30 days of this report being completed.

In Part II, fill in Patient complains of and, under History, include hospitalizations within the past five years.

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):

In II B. Mental Health and Cognitive Examination - Assessment and Plan, for each diagnosis: Diagnosis, Onset Date, If known, date of diagnosis, Anticipated duration, List of Medications and Treatment Plan. Fill in which diagnosis, if any, is a result of accident or injury, and if applicable, a general description.

In Part 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.

In Part IV - Effect on Activities of Daily Living: 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:

Activity: Check if yes. If yes, please describe the impact on daily activities: (Attach additional page if needed)

The activities are: Personal hygiene and dressing, Ordinary housework, Food shopping, Driving, Managing medications, Using a computer, Placing an emergency phone call, Visiting family and/or friends, Other.

Part V - Conclusions: Does this patient have a physical, mental health, or cognitive impairment(s) affecting ability to work? (Check one of the following.)

No, this patient does not have a physical, mental health, or cognitive impairment(s) affecting his or her ability to work.

Yes, this patient does have a physical, mental health, or cognitive impairment(s) affecting his or her ability to work which is NOT expected to last sixty (60) days or more. Yes, this patient does have a physical, mental health, or cognitive impairment(s) affecting his or her ability to work AND the impairment(s) is expected to last: 60 to 90 days, 3 to 6 months, 6 to12 months, more than a year. Yes, this patient has a physical, mental health, or cognitive impairment(s) that does not meet or equal the Department's Medical Standards or the SSI Listing of Impairments but does affect his or her ability to work AND the impairment(s) is expected to last: 60 to 90 days, 3 to 6 months, 6 to12 months, more than a year.

This Medical Report must be signed by a Competent Medical Authority. Per 106 CMR 701.600, a Competent Medical Authority is a physician, physician's assistant, osteopath, nurse practitioner, or psychologist licensed by the Commonwealth of Massachusetts, including a physician or psychiatrist from a Veterans Administration Hospital or clinic or from a Massachusetts Department of Mental Health facility or, for the limited purpose of diagnosing pregnancy and pregnancy-related incapacity, a nurse-midwife or who meets the educational and certification requirements mandated by Massachusetts state law and/or regulations.

Fill in the Printed Name of Competent Medical Authority, Telephone Number, Address (Street, City, State, Zip Code), Signature of Competent Medical Authority and Date.

Complete the EAEDC Medical Report in full with respect to the conditions that are relevant to the patient. This report must be completed in its entirety, signed and returned to the patient or mailed to: DTA Document Processing Center, P.O. Box 4406 Taunton, MA 02780-0420 Or fax to (617) 887-8765 indicated on page 11.