County welfare departments in California send the CW 61 when a CalWORKs or CalFresh applicant or participant reports a physical or mental condition that limits work, training or education. The provider states whether the condition is medically verifiable, its onset and expected duration, whether the person can work and for how many hours, and whether someone must be home to give care. The county uses the answers to grant an exemption or assign suitable welfare-to-work activities.
The patient completes and signs Section 1, the authorization to release information, and the county worker checks which provider type and which questions apply. The physician, psychologist or other licensed or certified professional completes Section 2, signs the Section 3 certification, and fills in CW 61A or CW 61B when attached.
The coversheet explains that non-exempt CalWORKs participants must take part in work, training or education for a set number of hours a week and make satisfactory progress, and that the county needs the provider's view of how the condition affects participation. It asks you to complete Section 2, sign the Section 3 certification and complete the Physical Capacities and/or Mental Capacities forms as appropriate, and lists the worker's name, phone and fax.
The county enters the case name and number and the worker's name and number. The worker checks which type of provider should complete Sections 2 and 3: a licensed physician or certified psychologist, or a health care professional licensed or certified by a state to diagnose or treat physical or mental impairments affecting work or education, such as medical doctors, osteopaths, chiropractors and psychologists.
The patient enters name, sex, birth date, Social Security number and the ages of children in the home, names the provider and clinic or medical group, and checks physical condition, mental condition or other. The authorization covers release to the county welfare department for up to one year and can be revoked. The patient signs and dates, and a witness, interpreter or person acting for the patient signs where needed.
Answer the questions the worker checked. Question 1 asks whether a medically verifiable condition limits or prevents certain tasks; if No, go straight to the certification. Question 2 asks the onset date and whether the condition is chronic or acute, with the date it is expected to last until. Question 3 asks about active treatment and the next appointment, question 4 whether the person can work and how many hours a day, and question 5 whether limitations affect work, education or training.
Question 6 asks whether the patient's condition prevents them from caring for the children in the home; the form explains the county needs this to decide whether child care must be provided so the other parent can work. Question 7 asks whether the patient's condition requires someone to be in the home to care for them. Answer Yes or No only where the worker checked these questions.
The provider or the provider's authorized representative signs, then prints name and title or specialty, mailing address, city, state, ZIP code, date signed and phone number. Question 1 sends you straight here when the answer is No. Return the form, with any attached CW 61A or CW 61B, to the worker named on the coversheet.
Download the current version from the source each time; forms change without notice.
Authorization to Release Medical Information (CW 61 Medical Report)
Autorizacion para Divulgar Informacion Medica
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The county worker checks one of two boxes: a licensed physician or certified psychologist, or a health care professional licensed or certified by a state to diagnose or treat impairments affecting work or training, including medical doctors, osteopaths, chiropractors and licensed or certified psychologists. The provider or an authorized representative signs the Section 3 certification.
Answer No to question 1, which asks whether the patient has a medically verifiable condition that would limit or prevent certain tasks. The form then says to complete only the Health Care Provider Certification in Section 3. A Yes answer means completing the rest of Section 2 and any attached Physical or Mental Capacities form.
Yes. CDSS posts CW 61(SP), Autorizacion para Divulgar Informacion Medica, with the same 7/01 revision, coversheet and three sections. The patient can sign the Spanish Section 1 authorization, and the provider sections ask the same questions as the English version.
Section 1 states the county welfare department may use the authorization for up to one year to obtain medical information. The patient can revoke it at any time, except for information already given to the department, and may request a copy of the completed form.