Abawd Work Program Requirement Medical Report Form printable pdf download

Give this form to DTA

Massachusetts Department of Transitional Assistance

 By Mail: DTA Document Processing

Supplemental Nutrition Assistance Program

Center, P.O. Box 4406,Taunton, MA

ABAWD Work Program

02780-0420

 By fax: (617) 887-8765

Requirement Medical Report

 In person at your local DTA office.

Patient/Participant Name __________________________________________________________

Address _________________________________________________________________________

_________________________________________________________________________________

The above listed individual requests verification of their physical or mental condition and/or participation

in your program. Please complete this form. You or the patient/participant should return it to the DTA

address listed above:

Patient/participant’s authorization

I hereby authorize the release of medical information and/or rehabilitation participation requested to the

Department of Transitional Assistance.

Signature ________________________________________

Date ___/____/________

Agency ID or Last 4

digits of SSN: ____________________

Please answer one or more of the following questions in the box below. Please sign and date this form

including your profession or position in your agency.**

1) Is this individual pregnant?

 yes  no  unknown

If yes, due date? ___/____/________

2) Is individual a participant in a vocational rehabilitation program, a mental health counseling program, or

a drug or alcohol treatment or counseling program? ___yes ___no

If yes, anticipated program end date: _________

3) Does this patient have a mental and/or physical illness or disability, temporary or permanent, which

reduces his or her ability to financially support him or herself? __yes ___no

If yes, please indicate the duration of the patient’s illness/disability

less than 30 days

 1-3 months

3-6 months



6 -9 months  9-12 months

more than 12 months/or indefinite

I certify that the information provided above is true and accurate.

____________________________________

________________________________

___/_____/_____________

Name (please print)

Title/profession**

Date form signed

____________________________________

__________________________________________________________

Signature

Address

Phone

** This form may be signed by any of the following: physician, physician’s assistant, designated representative of the

physician’s office, nurse practitioner, osteopath, licensed or certified psychologist, drug and alcohol abuse counselor, certified

mental health counselor, licensed independent clinical social worker, licensed certified social worker, and certified midwife.

For purposes of verifying an individual’s participation in a rehab or counseling program (question #2), the director of the

program or the individual’s counselor may also sign this statement.

ABAWD-WP-MED-RPT (Rev. 11/2015)

09-320-1115-05

Abawd Work Program Requirement Medical Report Form

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