Maine's Office for Family Independence uses this one-page form to decide whether a SNAP recipient is exempt from work requirements. A medical or behavioral health provider certifies whether the person is regularly participating in substance use disorder treatment, whether they are unable to work 30 hours a week, what limitations they have and how long those limitations will last.
A licensed medical or behavioral health provider, including a substance use disorder treatment provider, completes and signs the certification statement on page 1.
Download the current version from the source each time; forms change without notice.
Supplemental Nutrition Assistance Program Medical and Behavioral Health Verification Form
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A licensed medical or behavioral health provider, including a substance use disorder treatment provider. They complete the certification statement on page 1, covering SUD treatment participation, ability to work 30 hours a week, limitations and their expected duration, then sign.
To the Maine DHHS district office shown on the form, by mail or email. The copy posted on the Office for Family Independence forms page is pre-filled with the Farmington district office as the return address, so the patient's own district office may differ.