Med 9 Form – Fill Out and Use This PDF

Name (Last, First, Middle)

Social Security Number

Date of Birth

Address

City, State, Zip Code

Client Telephone Number

Printed Name of County Representative

County Telephone Number/FAX number

County



1. I find this individual has been or will be totally and permanently disabled to the extent they are unable to work

(If this box is

full time at any job due to a physical or mental impairment. This disability is expected to last 12 months or

more. Select the Qualifying Disability:

checked,



Respiratory disorders, such as cystic fibrosis, chronic persistent lung infections, or chronic pulmonary

please also

insufficiency;

select the



Cardiovascular disorders, such as chronic heart failure despite medication, congenital heart disease, or

qualifying

recurrent arrhythmias not related to a reversible cause;

disability-



Digestive disorders, such as liver dysfunction or gastrointestinal hemorrhage;

more than 1



Genitourinary disorders, such as chronic renal failure resulting in chronic hemodialysis;

may be



Hematological disorders, such as sickle-cell disease, hemophilia, or aplastic anemia;

selected)



Congenital disorders, such as fragile X syndrome or phenylketonuria (PKU);

 Neurological disorders, such as multiple sclerosis, muscular dystrophy, head trauma,

or cerebral palsy;

 Disorders of speech or other senses, such as blindness, tinnitus in combination with progressive hearing

loss, or loss of speech;

 Musculoskeletal disorders, such as a gross anatomical deformity, spinal stenosis or other spinal disorder

resulting in nerve root compression, or amputation of both hands;

 Mental or cognitive disorders, such as schizophrenia, affective disorders, personality disorders,

developmental disabilities, or substance abuse to the extent that the disorder results in at least two of the

following activities: -Marked restriction of activities of daily living; -Marked difficulties in maintaining social

functioning; -Marked difficulties in maintaining concentration or pace; -Repeated decompensation for

extended periods.

 Other (please define):__________________________________________________________________



2. I find this individual is not totally disabled but does have a physical or mental impairment that substantially

precludes this person from engaging in his/her usual occupation. This condition has been or will be for a

period of (check one):  6 months  7 months  8 months  9 months  10 months  11 months  12 months

Physical exertion is limited to (check all that apply):  light  sedentary  moderate

Please identify the less severe conditions preventing the individual from employment:___________________

_______________________________________________________________________________________



3. I find this individual does not have a total physical or mental impairment that has lasted or is expected to last

6 months.



4. PRIMARY DIAGNOSIS IS ALCOHOLISM OR CONTROLLED SUBSTANCE ADDICTION

Checking this box means there is no other physical or mental disability(ies) that precludes this person from

working other than his/her alcohol or controlled substance addiction. (If this box is checked, the individual

will be offered treatment through ADAD and will be expected to work once treatment is complete.)

If this is a Medical Re-examination, please answer this question if number 2 above was checked

Yes No

Has there been improvement in this client’s physical/mental condition that would allow the client to return to work?

This form may be completed by the following: (Please check one)

PRINTED NAME, ADDRESS, AND PHONE NUMBER.

Examining physician

Physician assistant certified in Colo.

This is needed to insure the accuracy of this report

Psychiatrist

Advanced practice nurse

Registered nurse licensed in Colorado

SIGNATURE:

STATE

LICENSE #

DATE OF EXAM

<![endif]>Supervisor

The physical/mental impairment (Box 2, Section 2 above) and other factors such as:

Signature of County Eligibility

County must complete the Residual Functional Capacity Scoring Matrix below and

Age, Training, Experience, or Education would render the person totally disabled from

having any employment that exists in the community for which they have competence.

document limitations in the case comments.

Supervisor/Supervisor Designee

(Date)

RESIDUAL FUNCTIONAL CAPACITY SCORING MATRIX

Score Zero (0)

Score One (1)

Score Two (2)

Score Three (3)

Points

Points

Point

Points

Points

Age (in years)

18-30

31-49

50-54

55-59

Education

GED, high school

7th through 11th

6th grade or less

Illiterate

diploma, or higher

grade

Communication Barriers

None

Mild

Moderate

Severe or Non-

English Speaking

<![endif]>Above

Previous Work History

Skilled

Semi-Skilled

Unskilled

None

<![endif]>Marked

Limitations Related to the

<![endif]>2 is

Ability to:

<![endif]>Boxif

● Remember,

None

Mild

Moderate

Severe

<![endif]>Department

● Understand,

● Carry Out Instructions

Limitations related to the

<![endif]>County

Ability to:

● Use Judgment,

● Concentrate, or

None

Mild

Moderate

Severe

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● Respond Appropriately

<![endif]>by

in a Work

<![endif]>Completed

Environment

Medical disability results

Disabled six (6)

Disabled six (6)

Disabled twelve

as reported on medical

(12) months or

Disabled less than

months or longer but

months or longer but

certification form, a

longer but able to

six (6) months.

able to work in some

able to work in some

Medicaid disability

work in some type

The client is

type of employment.

type of employment.

determination, or other

of employment.

ineligible for AND-

Physical exertion

Physical exertion

medical evidence

Physical exertion

SO.

limited to sedentary,

limited to light or

obtained by the county

limited to light or

light, or moderate.

sedentary.

department

sedentary.