State and county forms that ask a clinician to report work capacity, disability or a care need for public assistance, or to examine foster and adoptive families.
State and county social services agencies ask clinicians to document a patient's condition for public assistance and to examine foster and adoptive families. The forms seen most are work-capacity reports for SNAP, cash assistance and disability programs, such as California's CW 61 Medical Report, Michigan's Medical Examination Report (DHS-49), Nevada's Medical Provider ABAWD Attestation (2941-EF) and New York's LDSS-4526. This hub lists 107 forms, grouped by state, including in-home care certifications like California's SOC 873, child care and adoption medical reports.
Most go back to the county or state office, caseworker or licensing agency named on the form. Some are issued per case and not posted online, like Michigan's DHS-49 and DHS-54A, which come from the caseworker or the Disability Determination Service. Nevada's 2941-EF asks for no diagnosis or treatment records, only work capacity and how long limits will last. Of these forms, 23 have a Spanish version. Vero Documents fills PDF forms from the visit note and the chart, and the clinician reviews and signs.
Examining clinician certifies that a foster/adoptive parent or staff member of a licensed child placing agency or residential child care facility is free of infectious disease and physically, psychologically and emotionally fit to care for children.
DHR-FCS-623Physician's physical examination and immunization record for a child in foster care or a licensed child care/residential facility, certifying freedom from contagious disease, with space for routine re-examinations.
Licensed medical provider indicates which listed severe impairments the applicant has, diagnoses, expected duration and supporting records, so DPA can grant Interim Assistance cash while the person's SSI disability application is pending.
Health care professional evaluates whether an Alaska Temporary Assistance Program (ATAP) adult's physical or mental condition limits work, full- or part-time hours, expected duration and suitable activities, for the family self-sufficiency plan and work exemptions.
Examining eye specialist or physician states whether the patient meets the program's blindness definition (central acuity 20/200 or less or a restricted visual field), the nature and severity of the impairment and its effect, for Adult Public Assistance Aid to the Blind.
FAA-1249AQualified professional states whether the applicant/participant has a temporary or permanent physical or mental condition or illness that prevents gainful employment or participation in work preparation (Jobs) activities, and its expected duration, for Cash Assistance and Medical Assistance eligibility.
Applicant self-discloses health history and a physician states whether the applicant is physically and mentally able to care for persons with developmental disabilities, for licensure of DDD child or adult developmental (foster) homes.
Autorizacion para Divulgar Informacion Medica
Documents whether a CalWORKs/CalFresh applicant or participant has a medically verifiable physical or mental condition that limits or prevents work, training or education, its expected duration, and whether someone must be home to care for them, so the county can exempt the person or assign suitable welfare-to-work activities.
Licensed medical professional assesses a prospective or current RCFE (assisted living) resident's diagnoses, medications, functional and cognitive status, dementia, hospice and restricted health conditions so the facility can decide whether it can meet the person's needs.
Programa de Servicios de Apoyo en el Hogar (IHSS) Formulario de Certificacion sobre el Cuidado de la Salud
Licensed health care professional certifies that the IHSS applicant/recipient is unable to perform one or more activities of daily living independently and would be at risk of out-of-home placement without IHSS, a precondition for authorizing or continuing IHSS hours.
CW 61AProvider indicates the extent, if any, to which a CalWORKs/CalFresh participant's current physical condition would interfere with work-related physical activities; attached to the CW 61.
CW 61BProvider indicates the extent, if any, to which a CalWORKs/CalFresh participant's current mental condition would interfere with the ability to work or take part in training; attached to the CW 61.
Physician reports diagnoses, TB status, medications, ambulatory and functional capacity and need for skilled nursing for a resident/client of, or applicant to, a licensed community care facility (adult residential, group home, STRTP, etc.).
Licensed professional orders specific IHSS paramedical services (e.g. injections, catheter/ostomy care, wound care, tube feeding) the recipient cannot perform, states the condition requiring them and the time needed, and directs their provision by unlicensed IHSS providers.
Physician or other medical professional describes the patient's mental impairment (memory, orientation, judgment) and whether the patient needs 24-hour supervision to prevent self-injury, supporting a county decision on IHSS Protective Supervision hours.
Physician reports the health of a prospective adoptive parent (physical and mental health, conditions that could affect ability to parent) for the agency/CDSS adoption home study, with optional HIV-result release to the agency and court.
Physician's physical examination of a child placed for independent or agency adoption (first and second medical reports for infants), documenting health, development and medical needs for the adoption investigation.
Health professional verifies a parent's physical or mental incapacity to care for their children, its expected duration and hours of care needed, establishing need for subsidized child care and development services.
Examining physician reports chronic conditions, hospitalizations, communicable disease and whether the applicant's (or household child's) health is suitable for fostering or adopting, for DCF foster/adoptive (and probate custodian) home approval.
Treating provider reports whether a physical or mental condition keeps the patient from participating in DSS employment services (Jobs First/TFA), how long it will last, return-to-work date and part-time capacity, so DSS can decide a temporary exemption.
DHS-ESA-SNAPWR02.01Qualified professional verifies a physical or mental disability, illness, injury or condition (or substance-use treatment participation) and its duration so DHS can exempt the person from DC SNAP work requirements.
CF-ES 2094Physician certifies that a disabled household member is temporarily or permanently disabled to the extent personal care is required, with ICD-10-CM diagnosis and expected start/end dates, so the caregiver can be excused from Temporary Cash Assistance work requirements.
Prescribing physician documents diagnosis, proposed psychotropic medication, dosage, risks/benefits and alternatives for a child in out-of-home (foster) care, supporting parental consent or the court authorization required by section 39.407, F.S.
Physician or registered nurse describes the applicant's disabling conditions and need for care so DCF can approve the Home Care for Disabled Adults (HCDA) subsidy that supports 24-hour in-home care by a relative or other caregiver.
Physician's examination of a child placed for adoption (general health and physical condition by body system, abnormalities, development) for the adoption record.
Form 806Medical professional reports diagnosis, expected duration, prognosis, treatment instructions and when the TANF or Food Stamp (SNAP) participant can take part in work activities, so DFCS can assign or defer work requirements.
Examining physician, psychologist or psychiatrist documents a parent's or adult caretaker's disability and inability to care for the listed children, for a 12-month period, to establish need for child care assistance payments.
IL444-0183AEvaluación Médica - Informe del Médico
Physician (or psychiatrist/psychologist for mental conditions) reports body-system findings, diagnoses, prognosis and functional capacity on a regular and continuous basis, used by IDHS Family Community Resource Centers and the Client Assessment Unit to approve TANF medical barriers/exemptions and AABD disability.
CFS 431-APrescriber requests the DCFS Guardian's consent to start, increase or change psychotropic medication for a youth in DCFS care, giving diagnoses, medications, doses and clinical rationale.
Physician summarizes health problems, physical capabilities (lifting, bending, walking), communicable-disease status and certifies the adult has no physical or cognitive limitation that would prevent parenting, for licensing of foster and adoptive homes.
Practitioner reports the health of each prospective foster (resource) family member to satisfy Iowa's licensing requirement that applicants be physically and mentally able to care for children.
Health care professional documents that a household member (parent, spouse or child) with a disability or incapacity needs care, how many days per week and for how long, supporting a K-TAP Kentucky Works exemption or time-limit hardship extension for the caregiving parent.
Provider certifies whether a SNAP recipient is regularly participating in substance use disorder treatment, is unable to work 30 hours per week, any limitations and how long they will last, to exempt the person from SNAP work requirements.
DHS/FIA 500Health care provider reports diagnoses, impairments, limitations and expected duration used to decide eligibility for federal and state programs and the customer's participation in employment or training (e.g. Temporary Cash Assistance work exemptions).
DHS/FIA 500-ACustomer claims inability to work (disability, pregnancy, or caring for an ill/incapacitated household member) and, when the caseworker requests it, a health care provider certifies the condition, for SNAP work-requirement (ABAWD) exemptions.
DHS/FIA 500-CHealth care provider with independent diagnostic authority states whether a physical, mental or emotional impairment (and any substance use) prevents work or work/training activity and how long it will last, to determine eligibility for Maryland's Temporary Disability Assistance Program (TDAP).
Licensed clinician states whether the patient has a disability or health condition (alone or combined) expected to last 60 days or more that substantially reduces or eliminates their ability to support themselves through work, for EAEDC state cash assistance eligibility.
Treating physician's examination findings, diagnoses and physical limitations used by MDHHS's Disability Determination Service (DDS/MRT) to certify disability for State Disability Assistance (SDA), FIP deferrals and Medicaid disability.
DHS-54AQualified medical professional verifies a Family Independence Program client's short- or long-term incapacity, its expected length, work limitations and need for reasonable accommodation, to defer or modify PATH work participation.
Licensed medical provider certifies a Home Help applicant/recipient's diagnoses, whether the condition is chronic, mobility/equipment needs and the ADL, IADL and complex-care tasks needing hands-on assistance, a prerequisite for Home Help personal care services.
Psychiatrist or psychologist reports mental status, diagnoses and prognosis for the DDS/MRT disability determination for State Disability Assistance, FIP deferral or Medicaid disability.
Psychiatrist or psychologist assesses the client's mental residual functional capacity for work for the DDS/MRT disability determination (State Disability Assistance, FIP, Medicaid).
DHS-54EVerifies a FIP/PATH participant's incapacity, its duration and work restrictions so the specialist can grant a deferral or reasonable accommodation from employment activities.
DHS-49-IEye examiner reports eye examination findings used by MDHHS DDS/MRT for blindness determinations (State Disability Assistance, Medicaid).
MDHS-EA-331Private physician reports medical findings, diagnosis, treatment, need for specialist exams and how the condition affects ability to work or take part in the TANF Work Program, for the MDHS Medical Review Unit's incapacity/deprivation and work-exemption decision.
Eye examiner records visual acuity, visual fields and eye findings so the State Supervising Ophthalmologist can decide blindness for Missouri Blind Pension, Supplemental Aid to the Blind and blindness-based MO HealthNet (Medical Review Team) eligibility.
CC-3EPhysician statement that a parent/caretaker has a physical or mental incapacity so severe it eliminates their ability to care for their children, with nature and duration, for child care subsidy eligibility.
Health care professional documentation of a child's emotional, developmental, movement, sensory or medical special needs to justify a higher child care subsidy rate.
Physician verification of the type, length and frequency of a parent's (or family member's) medical, mental health or substance treatment appointments, so child care subsidy can cover that time.
Licensed health care professional's report verifying a medically determinable severe, chronic disability and support needs, for the state Disabled Persons and Family Support (DPFS) program.
Physician or certified provider certification of a positive HIV test, required for Housing Opportunities for Persons With AIDS (HOPWA) assistance.
Licensed medical professional's statement of whether a SNAP able-bodied adult without dependents (ABAWD) can do 80 hours/month of work activities, and whether limits are temporary or permanent, for the ABAWD work-requirement exemption.
Healthcare provider statement of a parent's diagnosis, onset, expected duration, treatment and whether the health problem (incapacity) makes it harder to care for the children, used for Financial Assistance to Needy Families (FANF/TANF) incapacity eligibility.
Form 1722Health history and provider statement for foster/adoptive family licensing applicants and household members, used by DCYF to verify state of health.
Ophthalmologist/optometrist report of visual impairment history, exam, diagnosis and prognosis, used by the state Disability Determination Unit for blindness-based state assistance (Aid to the Needy Blind) and related disability determinations.
Examining physician's report of all medical, psychiatric and substance use conditions, expected duration and functional limitations, used by local social services districts to decide Temporary Assistance/SNAP work-requirement exemptions or limitations, SSI referral and alcoholism/drug addiction determinations.
Medical report from a physical exam within one year, required for certification or approval of foster and foster/adoptive parent applicants and at reauthorization.
LDSS-3239Medical evaluation of a prospective or current Adult Family-Type Home operator to judge suitability to care for 1-4 dependent adults.
Medical evaluation of a dependent adult before admission to (and while living in) a certified Family-Type Home for Adults, to confirm they do not need constant medical care and to set the level of care.
Medical report for adoption-only applicants confirming freedom from communicable disease or conditions that might affect care of an adopted child, based on an exam within one year of application.
DSS-8209Verification of pregnancy, treatment-program participation, or medical conditions limiting work to under 20 hours/week, used by county DSS for Food and Nutrition Services (SNAP) work-requirement exemptions.
DSS-5156Medical report on a foster parent applicant or household member, including TB risk screening, flagging conditions that may interfere with caring for a foster child.
DSS-5206Provider summary of a foster child's initial health visit within 7 days of placement (conditions, medications, immunizations, follow-up, psychotropic review), given to the caregiver and DSS.
DSS-5209Provider summary completed at each well visit of a child in DSS custody, documenting health status, medications and follow-up for the foster care record.
Physician report of conditions and work limitations used by county social/human services agencies (Work First) to plan employment services, training or referral (including vocational rehabilitation).
Physician or psychologist medical report on severity and duration of impairments, released to county DSS and the state Disability Determination Section for disability-based assistance decisions.
Physician's certification of examination findings for an adoptee, filed with the agency's report to the Clerk of Superior Court in an adoption proceeding.
Physician certification that an adopted/adoptive child has a health condition expected to cause significant, lasting impairment, for Special Children Adoption Incentive Fund eligibility.
Medical professional's verification of a physical exam within 12 months, medication effects and capability to care for children, required before an initial family foster care license.
JFS 07302Physician's exam findings, diagnoses, health status and physical functional capacity, used by county JFS agencies to determine disability for Disability Financial Assistance (DFA).
Rating of understanding/memory, concentration/persistence, social interaction and adaptation limits, used with JFS 07302 to determine DFA disability for mental impairments.
04AF008EExamining physician's report on whether a resource (foster/adoptive) parent applicant has conditions that prevent or limit safely caring for children with medical or behavioral needs; a physical exam is required before approval.
Sent with a person receiving DDS services to each health care appointment; the provider records diagnosis/test results, recommendations, treatments, medication changes, staff monitoring instructions and tardive dyskinesia monitoring.
Licensed health care provider attestation that a patient depends on electrically powered prescribed equipment or refrigerated medication, used to decide eligibility for life-threatening energy crisis assistance.
Physician (or school designee) verification of diagnoses, developmental disability and functional limitations so an unpaid full-time caregiver can receive DDS respite vouchers.
Documents a medical (or religious/personal) exemption from the TANF requirement that children's immunizations be current, for children not attending school or child care.
Examining provider's determination that a public assistance applicant/recipient is permanently disabled, temporarily disabled (12+ months or under 12 months) or employable, with diagnosis and basis, used by the County Assistance Office for disability-based eligibility and work-requirement exemptions.
CD 878Physician or psychologist statement of a parent's disability and whether it prevents working/training or caring for the children, used by the Early Learning Resource Center to decide subsidized child care eligibility.
Application for state-funded coverage of listed antipsychotics for people with schizophrenia who are not on Medical Assistance; the prescribing physician attests to the diagnosis.
Physician, PA or CNP opinion on a foster or adoptive parent applicant's freedom from physical or mental illness detrimental to the care of children, for licensing/approval.
Prescriber's record of each psychotropic medication evaluation for a child in DCS custody (DSM diagnosis, symptoms, medication starts/changes/refills), sent to DCS for consent oversight.
Medical professional's TB screening and recommendation on whether a foster/adoptive parent applicant or other household adult has conditions affecting the ability to care for children.
Health care provider screening within 72 hours of a child entering DCS custody, documenting urgent needs and infectious disease before a comprehensive exam.
CS-4286Provider report of a visit (comprehensive exam/well-child check, treatment, dental, therapy, lab) for a child in DCS custody, with caregiver instructions, referrable conditions and follow-up.
Licensed treating professional's verification of the most recent visit, supporting continued adoption assistance (subsidy) for a child's medical or mental health needs.
Physician statement of whether a SNAP or TANF applicant/recipient claiming a disability can work or take part in work-preparation activities (full/part time, restrictions, permanent or temporary), used for work-requirement exemptions and Texas Workforce Commission referrals.
Documents each health care visit (including the 3-day medical exam after removal, Texas Health Steps checkups, dental, vision, hearing and CANS behavioral assessments) for a child in DFPS conservatorship, meeting licensing, contract and CPS policy requirements.
Physician statement that a TANF/SNAP caregiver is needed in the home to care for a disabled family member, and how many hours the caregiver can work, used for work-requirement exemptions.
Medical provider verification that a claimed disability is permanent as defined by the Social Security Administration, when the disability is not obvious to the eligibility worker (SNAP/TANF disability provisions).
Physician orders requested by a Day Activity and Health Services (DAHS) provider for initial approval, changes in condition, and supplemental nursing orders.
Treating physician's assessment documenting end-stage renal disease and treatment for eligibility in the state Kidney Health Care (KHC) assistance program.
Treating physician, clinic or hospital report on a cancer diagnosis and functional impact, requested by a vocational rehabilitation counselor to help determine eligibility for services.
Examining physician's medical findings used to determine TANF (or Medical Assistance Only) eligibility based on a parent's physical or mental incapacity.
Health care professional's verification of an impairment that prevents basic work activities in any occupation, required for time-limited General Assistance cash eligibility.
Medical report on a Reach Up (TANF) or 3SquaresVT participant's ability to take part in training and employment activities, used to set deferrals or modified work requirements.
DSS-822Medical evaluation a TANF applicant/recipient must return to verify a claimed disability for TANF eligibility (and related work-program exemption); missing forms lead to denial.
Health care provider statement of a WorkFirst (TANF) parent's or a cared-for family member's condition, work limitations and weekly participation hours, used to defer or limit required work activities.
DSHS 13-021Examining provider's physical functional evaluation used by DSHS to decide incapacity for state-funded Aged, Blind or Disabled (ABD) cash assistance and Housing and Essential Needs (HEN) referral, and to rate work limitations.
DCYF 13-001Medical provider's report on a foster care applicant or kinship caregiver's medical conditions, medications and prognosis, so Licensing can assess ability to care for children.
DSHS 13-865Mental health evaluation with DSM diagnoses and a medical source statement rating basic work activities, used to determine incapacity for ABD cash assistance and HEN referral.
DCYF 13-001BMental health provider's report on a foster care applicant or kinship caregiver's mental health conditions, treatment and any concerns about caring for children, for foster licensing.
DCF-F-DWSP2012-EMedical professional's report of a Wisconsin Works (W-2) participant's conditions, work/training capacity and accommodations, used by the W-2 agency to assign activities and decide placements.
DCF-F-126-EMental health professional's report on a W-2 participant's diagnoses and functional limitations, used to assign appropriate work, training and treatment activities.
DCF-F-5566-EProvider documentation that one parent in a two-parent or three-generation household is unable, due to disability or health condition, to care for the children or take part in an approved activity, for Wisconsin Shares child care subsidy eligibility.
DCF-F-DWSP10786Medical provider statement of a family member's incapacity and personal care needs, used by W-2 to excuse or limit a caregiver's work participation.
Medical verification that an unmarried W-2 applicant is in the third trimester of a high-risk pregnancy that prevents work, for the W-2 At Risk Pregnancy placement payment.
DCF-F-CFS0828Required health examination report for each adoptive parent (DCF 50.05(6)(h)), filed in the adoptive family record.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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A licensed physician or certified psychologist, or another health care professional licensed or certified to diagnose and treat the condition, as checked by the county worker. The provider completes Section 2 (questions 1 to 7) and the certification in Section 3; the patient signs the release in Section 1. When the county checks them, you also complete the CW 61A Physical Capacities or CW 61B Mental Capacities. The form goes back to the county worker named on the coversheet.
Nevada's Medical Provider ABAWD Attestation (2941-EF) asks whether a SNAP able-bodied adult without dependents can do 80 hours a month of work activities, whether limits are temporary or permanent, how long they will last, and a lay description of the limitation. DC's SNAP Work Requirement Medical Form (DHS-ESA-SNAPWR02.01) asks a qualified professional to verify the condition, or substance use treatment, and its duration. DC accepts a wide range of professionals, including counselors and community health workers.
Sometimes. Washington DSHS tells providers to bill DSHS, not the client, for the DSHS 10-353, and pays for the DSHS 13-021 physical evaluation through ProviderOne when recent chart notes are attached. Mississippi reimburses the physician for the MDHS-EA-331, and Missouri pays for the IM-68 eye exam at the Medicaid rate. Michigan's DDS may pay for requested DHS-49 reports, and California's SOC 321 exam can be billed to Medi-Cal as an office visit.
Each state has its own. Examples here include Connecticut's Physician's Statement for Foster Care or Adoptive Applicant (DCF-357), New York's Foster/Adoptive Applicant Medical Report (OCFS-5183D), Tennessee's Foster Parent/Other Adult Medical Report (CS-0678) and Illinois' Medical Evaluation of an Adult in a Foster or Adoptive Home (CFS 604). A physician completes them, and most also accept an NP or PA. The report goes to the licensing or adoption agency; Connecticut's is sent by the examining provider directly to DCF.