Who can complete Florida's HCDA medical statement?

A physician or registered nurse. DCF addresses the form to them, attaches the applicant's signed Confidential Information Release, and asks them to list diseases and treatments, physical and mental limitations with duration, a statement of general health and a recommendation on living arrangements.

What does 'not appropriate' mean on the CF-AA 1020A?

The 'not appropriate' choice applies when the applicant does not need a 24-hour caregiver and can live independently at home, or when an institutional setting is more appropriate. The other choice confirms the program fits because the 24-hour caregiver offers an alternative to nursing home or other institutional care.

Florida CF-AA 1020A Home Care for Disabled Adults

Who completes it

A physician or registered nurse completes Sections I to IV and signs. DCF Adult Services fills in the addressee and applicant details and attaches the applicant's signed Confidential Information Release.

Submitting and payment

How to submit it: Return the completed form to DCF Adult Services at the mailing address and attention line entered at the bottom.
Who pays: The form sets no fee and does not say who pays for completing it.

Good to know

Section I lists each disease, whether it is stabilized or controlled, and its medications or treatments.
Physical and mental limitations in Section II each need a stated duration.
Section IV is a single choice: the program is appropriate because the 24-hour caregiver is an alternative to institutional care, or it is not appropriate.
The subsidy covers basic support and maintenance, basic medical costs and a special supplement for health-related or in-home supportive services, as the form explains.

Get the official form

Download the current version from the source each time; forms change without notice.

Home Care for Disabled Adults Program Medical Statement

Official page PDF

All Social services forms

CF-ES 2094

Statement of the Need for Care

Physician 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.

Completed by: Physician (state license number required)
Issued by: Florida Department of Children and Families, ACCESS Florida (Economic Self-Sufficiency)
Format: Fillable PDF
Language: English

Official page PDF Form details

CF-FSP 5339

Medical Report for Prescribing Psychotropic Medication to a Child in Out-of-Home Care

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.

Completed by: Prescribing physician (psychiatrist, pediatrician) or ARNP/PA as permitted
Issued by: Florida Department of Children and Families
Format: Word document
Language: English

Official page Word file Form details

CF-FSP 5073

Physician's Report on Child (Child Placed for Adoption)

Physician's examination of a child placed for adoption (general health and physical condition by body system, abnormalities, development) for the adoption record.

Completed by: Examining physician
Issued by: Florida Department of Children and Families
Format: Fillable PDF
Language: English

Official page PDF Form details

2941-EF

Medical Provider ABAWD Attestation

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.

Completed by: Licensed medical professional
Issued by: Nevada Department of Human Services, Division of Social Services (DSS, formerly DWSS)
Format: Fillable PDF
Language: English and Spanish

Official page PDF Versión en español Form details

CW 61

Authorization to Release Medical Information (CW 61 Medical Report)

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.

Completed by: Licensed physician or certified psychologist, or another health care professional licensed/certified to diagnose and treat (MD, DO, chiropractor, psychologist), as checked by the county worker
Issued by: California Department of Social Services
Format: Fillable PDF
Language: English and Spanish

Official page PDF Versión en español How to fill it in

DCF-F-DWSP2012-E

Medical Examination and Capacity

Medical 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.

Completed by: Medical professional treating or examining the participant
Issued by: Wisconsin Department of Children and Families (DCF), Division of Family and Economic Security
Format: Word document
Language: English