Employability Re-Assessment Form Pa 1664 - Department Of Public Welfare Page 3
Download a blank fillable Employability Re-Assessment Form Pa 1664 - Department Of Public Welfare in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Employability Re-Assessment Form Pa 1664 - Department Of Public Welfare with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3SECTION II
(To be completed by a licensed physician, physician’s assistant, certified registered nurse practitioner, or psychologist)
Previously, the patient provided an Employability Assessment Form documenting that he or she could not work due to a temporary
disability. The patient is requesting a continuation of assistance or an exemption from work requirements or has reapplied for assistance.
For eligibility (or exemption from work requirements) to continue or be re-established, please complete this section based on your
evaluation of the patient’s statement in Section I, your examination of the patient, and your use of other medical procedures.
EMPLOYABILITY (Check only one)
1.
PERMANENTLY DISABLED - Based on my assessment, I find that the patient now has a physical or
mental condition which permanently precludes any gainful employment. The patient is a candidate for
Social Security Disability or SSI.
2.
TEMPORARILY DISABLED - 12 MONTHS OR MORE - Based on my assessment, I find that the patient
remains disabled due to a temporary condition as a result of an injury or an acute condition and the
disability temporarily precludes any gainful employment.
The temporary disability began
and is expected to last until
.
DATE
DATE
The patient continues to be temporarily disabled because _________________________________________________________
___________________________________________________________________________________________________________________________
Did the patient pursue the prescribed treatment for the disability?
Yes
No
Don’t know
The patient may be a candidate for Social Security Disability or SSI benefits.
3.
TEMPORARILY DISABLED - LESS THAN 12 MONTHS - Based on my assessment, I find that the
patient remains disabled due to a temporary condition or as a result of an injury or an acute condition
and the disability temporarily precludes any gainful employment.
The temporary disability began
and is expected to last until
.
DATE
DATE
The patient continues to be temporarily disabled because _________________________________________________________
___________________________________________________________________________________________________________________________
Did the patient pursue the prescribed treatment for the disability?
Yes
No
Don’t know
4.
EMPLOYABLE - Based on my assessment, I found that the patient’s physical and/or mental
condition is such that he or she can work.
EXAMINATION RESULTS: (Both parts of this Section must be completed if #1, #2 or #3 above is
checked. If not completed, the client will be ineligible for GA.)
1.
DIAGNOSIS (Primary and Secondary):
PRIMARY:
SECONDARY:
2.
ASSESSMENT BASED UPON: (Check all that apply)
A.
PHYSICAL EXAMINATION
E.
OTHER (Specify) _______________________________________________
B.
REVIEW OF MEDICAL RECORDS
__________________________________________________________________
C.
CLINICAL HISTORY
D.
APPROPRIATE TESTS AND DIAGNOSTIC PROCEDURES
AS A LICENSED MEDICAL PROVIDER, I CERTIFY THAT I HAVE READ AND COMPLIED WITH THE ATTACHED INSTRUCTIONS AND THE
ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY PROFESSIONAL KNOWLEDGE. I FURTHER CERTIFY THAT MY
DIAGNOSIS AND ASSESSMENT ARE BASED SOLELY ON THE PATIENT’S CONDITION AS DETERMINED BY MY EXAMINATION. I
UNDERSTAND AND AGREE THAT MY DIAGNOSIS AND SUPPORTING DOCUMENTATION MAY BE SUBJECT TO REVIEW BY THE
DEPARTMENT OF PUBLIC WELFARE.
MEDICAL PROVIDER (PRINT NAME):
TELEPHONE NO.:
ADDRESS:
SIGNATURE
MEDICAL ASSISTANCE PROVIDER NO.
DATE
PA 1664 (SG) 2/10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Lea-pst - Safety Telecommunicator Training Paperwork Checklist Form - New Mexico Department Of Public Safety Training Center
Legal
Continuation Of Certification Annual Firearms Training Report Form - New Mexico Department Of Public Safety Training Center
Legal
Application For Approval Of Sanitary Facilities For A Realty Subdivision Form - Monroe County Department Of Public Health
Legal
Ears/hearing Accomodation Field Exam Form - New Mexico Department Of Public Safety Training Center
Legal
Related Categories
Parent category: Legal