Pa 635 Form – Fill Out and Use This PDF

Commonwealth of Pennsylvania Department of Public Welfare

MEDICALASSESSMENTFORM

This Medical Assessment Form (PA 635) is needed to determine whether an individual is able to participate in employment and training activities, what treatment plan(s) could help the individual move towards employment, or determine if the individual is a good candidate for disability benefits or is pregnant.

COMPLETED BYCOUNTYASSISTANCE OFFICE

Client’s Address (Street, City, Zip Code)

Instructions to Medical Provider

This form may be completed by a counselor, social worker, or mental health therapist, but must be agreed upon and signed by a physician, psychologist, physician assistant or certified registered nurse practitioner.

Please complete the appropriate section(s) of this form and return (fax or mail) to the county assistance office (above) by

________________.

Confirmation of Pregnancy

If this individual is pregnant, give expected delivery date. _____/_____/_____

Date

NOTE: IF PREGNANCYDOES NOT AFFECT THIS INDIVIDUAL’S ABILITYTO WORK, ONLYCOMPLETE SECTION I OF THIS FORM.

SECTION I MEDICALPROVIDER INFORMATION Please complete this entire section.

Printed Name of Medical Provider: ____________________________________________________

Medical License Number: ___________________________ NPI Number: ____________________

(If Applicable)

Phone Number ( ): ____________________________

Address: ___________________________________

___________________________________

___________________________________

I certify that all of the information provided on this form is true, correct and complete to the best of my professional knowledge. I further certify that, the diagnosis and assessment related to this client’s health condition are based on his/her medical condition as determined by examination and knowledge of this client’s medical history.

I understand and agree that the diagnosis and supporting documentation may be subject to review by the Department of Public Welfare’s Medical Review Team.

Signature of medical provider must be original or the form is invalid. Rubber stamps, labels or other reproductions are not acceptable.

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Prepared by	Date
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Signature of Medical Provider	Date
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County/Record NumberClient’s NameDate of Birth

SECTION II EMPLOYABILITY

IF CHECKBOX 1 IS SELECTED FOR THIS INDIVIDUAL, DO NOTCOMPLETE SECTION III.

IF EMPLOYABLE, THIS INDIVIDUALWILLHAVE THE REQUIREMENT TO WORK OR PARTICIPATE IN TRAINING FOR ______ HOURS PER

WEEK. PLEASE SELECT ONE OF THE FOLLOWING BASED ON YOUR BEST ESTIMATE OF THE INDIVIDUAL’S CURRENT CAPABILITIES:

1. EMPLOYABLE –

This individual is able to work or participate in training, on a sustained basis, for the hours that are required per week (see above).

with the following reasonable accommodations: ___________________________________________________________________

_____________________________________________________________________________________________________________

2. LIMITED EMPLOYABILITY – Please check all that apply. Please also complete Section III.

This individual is able to work or participate in training, on a sustained basis, for fewer than the hours that are required per week (see above). Approximately how many hours can the individual participate per week? __________________

With the following reasonable accommodations

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

What is the recommended treatment plan to remediate this condition so this individual is able to work or participate in training, on a sustained basis, for the hours that are required per week (see above) or to increase the hours of participation?

Prescribed Medication

Therapy: ________ hours per week Type: _____________________________________________________________________

Follow-up with specialist: Specialty ______________________________ Name of Physician_______________________________

Referral Made for Patient? __________

Other (describe): ___________________________________________________________________________________________

This individual is expected to be limited from being able to work or participate in training for the number of hours indicated above on a

sustained basis, until ____ / ____ / ______.

Date

3. TEMPORARYINCAPACITY – Please also complete Section III.

This individual’s physical or mental condition precludes him/her from participating in any form of employment or training activity, on a sustained basis, at this time, but the condition is expected to improve within 12 months.

This individual’s temporary incapacity is expected to prevent working or participation in training until ____/____/______.

Date

What is the recommended treatment plan to remediate this condition so this individual is able to work or participate in training, on a sustained basis, for the hours that are required per week (see above) or to increase the hours of participation?

Prescribed Medication

Therapy: ________ hours per week Type: _____________________________________________________________________

Follow-up with specialist: Specialty ______________________________ Name of Physician_______________________________

Referral Made for Patient? __________

Other (describe): ___________________________________________________________________________________________

4. DISABLED – Please also complete Section III.

This individual has a physical or mental condition that is expected to last for 12 months or more, and precludes any form of employment, on a sustained basis, of at least 30 hours per week. The individual is a candidate for Social Security Disability or Supplemental Security Income.

The disability begin date _____/_____/_____.

Date

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County/Record Number

Client’s Name

Date of Birth

SECTION III DIAGNOSIS (ES)

Include name of each Diagnosis with ICD-9 code and description. Please explain how each diagnosis affects the client’s ability to work.

Primary Diagnosis:

Secondary Diagnosis:

Tertiary Diagnosis:

Other Diagnosis:

The individual is following the prescribed treatment plan.

_____ Yes _____ No _____Don’t Know If No, indicate:

Not taking medication as prescribed

Not following up with specialist

Not eligible or appropriate for needed medication or treatment. Explain: ________________

___________________________________________________________________________

___________________________________________________________________________

Other (describe): _____________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

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