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Maryland DHS/FIA 500 Medical Report Form

Maryland's Family Investment Administration uses Form 500 to decide eligibility for federal and state programs and whether a customer must take part in work, training or education. The provider rates how many hours in an 8-hour day the person can sit, stand, walk, climb, bend, squat and reach, and reports mental health, learning disabilities, substance use, expected duration and capacity to work.

Who completes it

A licensed health care provider with independent diagnostic authority completes Sections A to D and signs with title and license number. The local Department of Social Services fills in the district office, case manager and customer details at the top.

Submitting and payment

How to submit it
Return the completed form to the case manager at the local Department of Social Services named at the top.
Who pays
The form sets no fee and does not say who pays for completing it.

Good to know

  • The form asks whether the impairment will last 12 months or more and, if shorter, whether the condition is expected to result in death.
  • Section D includes a question for a parent of a disabled child: whether the child's condition requires the parent at home full time.
  • Activity tolerances are rated from never to 8 hours, with options for no restrictions or unknown.
  • A Spanish edition is posted, and related forms are the 500-A Verification of Disability and the 500-C TDAP Medical Report.

Get the official form

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

Medical Report Form 500

Official pagePDFVersión en español

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

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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Frequently asked questions

Who can sign Maryland's Medical Report Form 500?

A health care provider with independent diagnostic authority who is authorized to evaluate, determine impairment and independently treat medical, mental or emotional disorders, and who practices under the requirements of their professional board. The provider adds their title, license number and practice address.

What is the difference between Forms 500, 500-A and 500-C?

Form 500 is the general FIA medical report used for program eligibility and work or training participation. Form 500-A is a short verification of disability used for SNAP work requirements, and Form 500-C is the medical report for Maryland's Temporary Disability Assistance Program (TDAP).