County MDHS offices send this report when a TANF parent claims a physical or mental incapacity, or asks to be excused from the TANF Work Program for medical reasons. The physician describes findings, diagnosis, treatment and how the condition limits work. The caseworker adds a Report of Social Information (MDHS-EA-332) and the state Medical Review Unit decides incapacity.
The private physician completes the whole report, from a new exam or from records of the patient's own exam and treatment within the past six months; a licensed nurse practitioner currently involved in the client's treatment may also sign. The caseworker writes the separate social report and the client signs a HIPAA release (MDHS-EA-903).
Download the current version from the source each time; forms change without notice.
Report of Medical Examination
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Five things: medical findings describing the impairment, a diagnosis, the treatment given and its effect or the treatment recommended, whether a specialist exam or special tests are needed, and how the condition affects the ability to work or take part in the TANF Work Program, including how long the disability is expected to last.
Yes. The MDHS TANF policy manual allows a licensed nurse practitioner who is currently involved in the client's treatment to sign the Report of Medical Examination. Otherwise it is completed by the private physician who examined the client, or who treated them within the past six months.
When an applicant asks for a medical exemption from the Work Program, the worker hands out the form with a 10-day return period. If the doctor's appointment falls later and the applicant documents a good-faith effort, the application can be held for up to 30 days.