DC's Department of Human Services uses this three-page form to excuse SNAP participants from work requirements. A qualified professional confirms a physical or mental condition that reduces the ability to work, with expected duration, or a pregnancy, or regular participation in substance use treatment or recovery services. DHS introduced the form in June 2026 with the expanded federal SNAP work rules.
A wide range of qualified professionals can complete Sections 3 and 4, from physicians, PAs, NPs and psychologists to therapists, counselors, community health workers and substance use counselors. The participant fills in Section 1 and signs the release in Section 2.
Download the current version from the source each time; forms change without notice.
SNAP Work Requirement Medical Form
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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Any qualified professional who can provide competent medical evidence: physicians, PAs, NPs, midwives, psychologists, social workers, mental health counselors, community health workers, podiatrists, optometrists, audiologists, physical, speech or occupational therapists, drug and alcohol counselors, rehabilitation staff and homeless outreach counselors, among others.
The participant or the professional returns the signed form to the DHS Economic Security Administration online through District Direct or its mobile app, by mail to the Case Record Management Unit, by fax, or by dropping it off at a DHS service center. The form advises keeping a copy.
Yes. Question 2 asks whether the individual is pregnant and, if so, the due date. Pregnancy is one of four situations the professional can confirm on the form, along with a work-limiting condition and participation in substance use treatment or recovery services.