Texas HHSC uses this two-page report when TANF or Medical Assistance Only eligibility depends on a person's physical or mental incapacity. The examining physician performs a basic physical examination and reports findings by body system, diagnosis, prognosis, onset, restrictions, work capacity and a return-to-work date, which the state Disability Determination unit uses to decide eligibility.
The examining physician completes everything below 'To be completed by examining physician' and certifies holding a currently valid US medical license. The eligibility worker completes the identification block, including the return address and medical authorization date.
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Report of Physical or Mental Examination
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No. The form asks for a basic physical examination and states that this does not include X-rays, diagnostic tests, hospitalization or treatment. The physician reports history, vital signs, body system findings, an estimate of mental condition, diagnosis and prognosis.
The HHSC worker checks the signature and dates, then routes the original to the Disability Determination unit with the related forms. That unit reviews the materials, makes the incapacity decision and sends its decision back to the worker on Form H3035.
Under recommendations, the physician lists restrictions, marks work capacity as no limitation, medium, light or sedentary work, and gives a return-to-work date. A date of onset and remarks are also requested, along with the date of examination.