Ohio county job and family services agencies send this two-page Basic Medical to decide disability for Disability Financial Assistance (DFA). The physician records vital signs and exam findings, conditions with ICD or DSM codes, history, health status and physical functional capacity, then answers whether the impairment prevents any substantial gainful activity for at least nine months.
A physician completes Section II, noting whether they are the individual's primary care physician, and signs a certification under penalty of law. The county caseworker completes Section I with the client's identifying information.
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Basic Medical
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The physician answers whether the individual is unable to engage in any substantial gainful activity because of a medically determinable physical or mental impairment that can be expected to result in death, or that has lasted or can be expected to last for a continuous period of not less than nine months.
Yes. The form was previously issued by Ohio Medicaid as ODM 07302 (Rev. 7/2018). The current version is JFS 07302 (Rev. 4/2022), issued by the Ohio Department of Job and Family Services for Disability Financial Assistance.
Item D lists improving, improving without treatment, improving with treatment, good or stable with treatment, poor but stable, and deteriorating. Item C asks for history including onset, duration, treatment, prescribed medications and prognosis, and item F asks whether more studies or treatment are indicated.