When a Connecticut DSS client says a medical condition keeps them from the department's employment programs, DSS mails this report to the treating provider. The provider states whether the condition prevents work, the written diagnosis, how long the inability will last, the return-to-work date and any part-time capacity, plus history, symptoms and prognosis, so DSS can decide on a temporary exemption.
A licensed provider currently treating the patient, whose scope of practice permits diagnosing and treating the condition, completes everything below the DSS worker's header and signs with license number. A licensed master social worker may complete it for mental health disorders with a qualified co-signer.
Download the current version from the source each time; forms change without notice.
Employment Services Medical Exemption Report
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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A licensed medical provider whose scope of practice under the Connecticut General Statutes permits them to diagnose and treat the condition, such as an MD, DO, APRN, PA or psychologist. A licensed master social worker may complete it for mental health disorders with a supervising clinician's co-signature.
No. The form asks for a written diagnosis only and tells providers not to use ICD-9 or ICD-10 codes. Describe the incapacitating symptoms or impairments and how they prevent work in the medical information section instead.
Check 'Less than 30 days' and enter the onset and return-to-work dates, then stop and go to the signature instructions on page 3. The part-time capacity and medical information questions are answered only when the inability to work is expected to last 30 days or more.