Georgia's Division of Family and Children Services (DFCS) sends this two-page statement when a TANF or Food Stamp (SNAP) participant reports a medical condition that affects work. The medical professional gives the diagnosis, expected duration and prognosis and estimates when the person can take part in work-related activities. DFCS uses the answers to place the person in a suitable activity, adjust requirements, or document incapacity.
DFCS fills in the TO and RE block with the client's name, case number and worker ID, and the participant signs the authorization to release medical information, with a witness if they sign by mark. The medical professional, such as a physician, nurse practitioner, physician assistant or psychologist, completes the lower part of page 1 and all of page 2.
DFCS addresses the form to you and enters the client's name, case number and worker ID, checks whether the person has applied for or receives TANF or Food Stamps, and fills in how many of the 48 TANF months the client has used. The worker named here is where the completed statement goes.
The client names you and authorizes you to give DFCS information about their medical condition, including their ability to take part in suitable work activities and their current or future employability. They sign or make their mark and date it; a witness signs and dates if they sign with an X. Confirm the release is signed before completing your section.
Enter the date of the most recent examination, the diagnosis of the present condition, the expected duration of the illness and the prognosis. The prognosis line asks you to be specific, so give the expected course rather than a single word. DFCS uses duration and prognosis to decide whether a requirement should change and for how long.
Describe the specific instructions the patient has been told to follow, such as rest, therapy or restrictions. Estimate when the patient will be able to take part in work-related activities. Then say what accommodations, if any, would let the patient participate now; this is where partial capacity, such as limited hours or seated tasks, should be described.
Check Yes or No for each activity: full-time employment, part-time employment, volunteer activity, light community service, adult literacy or GED, and short-term technical training. Note any needed accommodations in the space above. Then answer whether the patient needs a full-time caretaker and enter a date to return for re-examination.
Use the additional comments lines for anything DFCS should know about the patient's condition or work capacity that does not fit the questions above. Print your name and address (the form asks you to print), sign, date and give a phone number so the caseworker can reach you with questions.
Download the current version from the source each time; forms change without notice.
Medical Statement
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Sources for this guide
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It tells DFCS about a TANF or SNAP participant's current medical condition and expected recovery so the caseworker can place the person in an appropriate work-related activity, set accommodations or defer requirements. In TANF, DFCS policy also lists it as medical evidence when a parent's incapacity is the basis for eligibility.
The form asks for a medical professional's statement and does not limit it to physicians. Physicians, nurse practitioners, physician assistants and psychologists who treat the client can complete it. The signer prints their name and address, signs, dates and adds a phone number so DFCS can follow up.
Yes. The DFCS forms appendix in the Policy and Manual Management System lists Form 806 SP, Declaración Médica, alongside the English Medical Statement, both at revision 06/16. The medical professional's questions are the same in both versions.
Georgia TANF policy requires an incapacity to be expected to last at least 30 days from the date of onset. DFCS reviews the medical evidence, including Form 806, with its own social data report, documents the nature and duration of the incapacity, and reevaluates it later depending on how long it is expected to last.