Form H1836-B - Medical Release/physician'S Statement

Form H1836-B - Medical Release/physician'S Statement - Texas

Texas Health and Human

Form H1836-B

Medical Release/Physician’s Statement

Services Commission

January 2006

Section I — To Be Completed By Staff

Name of Patient

Date of Birth

Social Security No.

- -

Patient’s Usual Job

Case Name (caregiver)

Case No.

Advisor’s Name

BJN

Office Address/Mail Code/Fax No.

Section II — To Be Completed By Physician

The person caring for the patient named above has applied for benefits with our agency. Federal and state regulations require that persons receiving

benefits work or participate in activities to prepare them for work unless they are unable to do so due to a circumstance such as being needed in the home

due to the patient’s disabling illness or injury. This person claims that circumstance. Please complete parts A and B below. After you complete the form,

you may give it to the person or mail it to HHSC at the address in Section I.

Part A – Caring For a Disabled Family Member

To what extent is the caregiver able to work or participate in activities to prepare for work? Please check one of the following boxes:

The caregiver is able to work, or participate in activities to prepare for work (outside or inside of their home), full time

(a) The caregiver is able to work or participate in activities to prepare for work (outside of their home), part time at

hours/week

(b) The caregiver is able to work or participate in activities to prepare for work (inside of their home), part time at

hours/week

The caregiver is unable to work or participate in activities. If you check this box, please indicate which of the following applies:

(a) The disability is permanent.

(b) The disability is not permanent and is expected to last more than 6 months.

If necessary, provide further detail: