W-300a - Medical Statement - State Of Connecticut
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1
2State of Connecticut
Department of Social Services
Medical Statement
W-300A
(Rev. 7/08)
The individual listed below has applied for help with the Department of Social Services. This person has told
us that he or she has a medical or psychiatric condition that will not allow him or her to work for at least 30
days. Your answers to the questions on this form will help us to determine the individual’s employability status
and/or disability status for our programs. If the patient is currently under your care, the report may be prepared
from your existing records.
Client Name:
Social Security Number:
Date of Birth:
Client ID Number:
Client’s statement of his/her medical condition: _________________________________________________
_______________________________________________________________________________________
Please answer the following based on your records and knowledge of the patient.
1. Does the patient have a significant medical condition that prevents him or her from working?
Yes
No
If yes, what is the diagnosis? _______________________________________
2. How much longer is this condition expected to last? (please check one)
Less than 30 days
More than 2 months but less than 6 months
More than 30 days but less than 2 months
6 months or more
When do you think the patient will be able to return to work? ____________
Date
3. Does the patient have a mental health or substance abuse problem?
Yes
No
If yes, which one? ____________________
Signature Instructions
Please print (or stamp) your name and sign below. This form may be signed by an M.D., D.O., Ph.D.,
Optometrist or, for diseases or injuries of the foot, a Podiatrist. If you are another type of medical professional,
for example, a nurse practitioner or physician’s assistant, you may complete this form but it must be co-signed
by an M.D., D.O., Ph.D., Optometrist or Podiatrist.
Name of person completing this form (print)
Title
Signature
Name of person co-signer, if required
Title
Signature
(print)
Provider type (specialty)
Date
Telephone Number
Fax Number
Important - See Reverse for Mailing and Billing Instructions
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