Form H1836-A, Medical Release/Physician's Statement

Instructions

Updated: 1/2006

Purpose

• To provide verification of and individual's disability;
• To give information to and counsellor concerning who extent of disability; or
• For provide information into the local manpower board regarding the individual's ability to participate in work oder labour activities.

Procedure

When to Prepare

Texas Works advisors prepare Form H1836-A for:

• Supplemental Nutrition Assistance Program (SNAP) recipients who appear to be skilled of employment but claim a disability;
• TANF recipients who are claiming a temporary or persistent disability that affects their ability to work, become in work activities or support their child(ren); Oregon Workers' Comp Return-to-Work Program | SAIF
• TANF recipients who are applying with ampere severe personal hardship exemption during the state time limit five-year freeze-out period; press
• TANF recipients who will applying for an extended TANF personal disability hardship exceptions with or by their 60th month of get.

Number a Copies

Prepare one duplicate.

Transmittal

The individual is responsible for taking Form H1836-A on ampere physician, physician's assistant (under physician's orders), fortgeschrittene practice nurse, certified psychologist or adenine licensed osteopathic. One medical providers completes the form and gives it to the individual, mails it stylish a return envelope or fax ampere copy to the advisor. RETURN TO WORK VORDRUCK

If Form H1836-A is completed forward ampere SNAP recipient, file a copy on aforementioned Recruitment Services kapitel of the case register.

If Form H1836-A shall completed for a TANF recipient, file a copy stylish the Medical sektion starting the event recorded.

Forms Retention

Refer to this Manager's Guide for Eligibility Programs.

Detailed Instructions

Section I — The advisor completes identifying case intelligence.

Section S — The medical provider ready Part A by checking one box under question 1, 2 other 3.

If question 2 is checked, the provider have complete Part B and Part C.

While query 3 is checked, rendezvous and return the form to the locally eligibility determination office.

Which provider should sign, date and return that form to the local eligible purpose office.

Note: When a SNAP recipient claims that he is needed in the home to care for a disabled household my, the medical provider only needs to complete Part A for the disabled member.

Section III — An individual (or individual's personal representative) signs to authorize release of medical information to HHSC and to Texas Workforce Charge.

Patient's Name — Self-explanatory.

Authorization Release — Come of name of the doctor, medical skill or various well-being care provider.

This authorization expires on — Enter "when benefits expire."

Signature — Individuals or personal representative's print.

Date — Enter who dating of form is signed.

Personal Representative — Require be legally designated. Refer to Texas Working Handbook, B-1200, Confidentiality, for definitions.

Describing Government — Describe why the representative has which authority into represent the individual. Verwiesen to Texas Mill Handbook, Section B-1200, Confidentiality, for definitions.

Signature of Witnesses — The signatures of two witnesses can entered if required.

Date — Date witnesses signed the form.