Wisconsin Works (W-2) case managers send this form to a participant's treating or examining medical professional before assigning work, training and education activities. The professional states whether a health condition limits participation for up to 40 hours a week and for how long, rates physical abilities such as lifting, sitting and standing, and recommends suitable activities, accommodations and weekly hours.
The medical professional completes every section below the agency box and signs by hand. The W-2 agency enters the patient and return details at the top and includes the patient's signed release of information.
Download the current version from the source each time; forms change without notice.
Medical Examination and Capacity
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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Whether a condition limits structured activities up to 40 hours a week and for how long; relevant facts, diagnosis and prognosis as they affect function; lifting, sitting, standing, fine motor and movement limits; suitable W-2 activities; needed accommodations; limits in reading, writing, computer use and group work; expected absences; weekly hours; and a review date.
Yes. The form asks whether, based on the patient's condition, the professional recommends that the patient apply for Social Security disability benefits with advocacy from the Wisconsin Works agency. The agency handles the application support.
The directions say to scan or mail the completed form to the Wisconsin Works agency named at the top and to attach the patient's treatment plan if applicable. The signature must be handwritten in blue or black ink.