Maryland DHS/FIA 500-A Verification of Disability

Qualified 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.

Completed by

Qualified professional: physician, physician assistant, nurse, nurse practitioner, licensed or certified psychologist, or social worker

Issued by

Arizona Department of Economic Security, Division of Benefits and Medical Eligibility

Format

Fillable PDF

Language

Bilingual

Health 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).

Completed by

Licensed health care provider

Issued by

Maryland Department of Human Services, Family Investment Administration

Format

PDF

Language

English and Spanish

Health 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).

Completed by

Health care provider with independent diagnostic authority (physician, NP, PA, licensed psychologist, LCSW-C)

Issued by

Maryland Department of Human Services, Family Investment Administration

Format

Fillable PDF

Language

English and Spanish

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

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

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