Ability To Work Report Form - Oneida County Dept. Of Social Services printable pdf download

ABILITY TO WORK REPORT – ONEIDA COUNTY CSA

Patient Name:

Date of Birth:

SSN:

____________________________________________________________________________________________

___

PLEASE SELECT ONE OF THE FOLLOWING OPTIONS:

_____

Patient is PERMANENTLY & TOTALLY DISABLED as of _______________________ (date).

_____

Patient is TEMPORARILY & TOTALLY DISABLED as of _________________________ (date) through

_________________________ (date) AND

On _________________________ (date), patient will be reevaluated.

Patient has been referred to ________________________________________ for further treatment/opinion.

Name/Address/City/State/Phone: ___________________________________________________________

______________________________________________________________________________________

_____

Patient is (Choose one: PERMANENTLY or TEMPORARILY) PARTIALLY DISABLED and has the following

work restrictions as of _________________________ (date), as follows/attached:

_____________________________________________________________________________________________

will be reevaluated on _________________________ (date) OR

will be released to return to work without restrictions on _________________________ (date).

1. State the medical problem(s) which cause the inability, including diagnosis and date of injury/illness:

2. Has the patient kept all appointments during the last six months? If not, list the missed appointments.

3. What is the date of the next appointment that the patient has with you?

4. What is the prognosis regarding the ability to work for the patient if she/he follows your recommendation?

(Please include list of recommendations)

5. What is the prognosis regarding the ability to work for the patient if she/he does not follow your recommendation?

6. What possible treatments (such as medications/surgery) would be likely to improve the patient’s ability to work?

Of these, which have already been tried?

7. Name any treatments the patient has refused to try.

Medical Provider's Signature (No Stamps): __________________________________________________ Date:_________________

Medical Provider's Printed or Stamped:

Please return to:

Name:

Oneida County Dept. of Social Services

Address:

Child Support Agency

City: _____________________________________________

P. O. Box 400

State: _____________________________________________

Rhinelander, WI 54501

Phone: ____________________________________________

FAX: 715-362-7910

Ability To Work Report Form - Oneida County Dept. Of Social Services