Title: _________________________________
Author: barinur
Last saved by: pellerp
Company: State of Florida

_________________________________				____________________________
^Name ^of ^Physician				^Date

Dear Physician,

I, ______________________, am requesting that the attached Medical Verification form be completed. 

In order to receive temporary cash assistance and prepare individuals and families for self-sufficiency, individuals receiving cash assistance are required to participate in countable work activities.  Additionally, Florida limits such families to receive cash assistance for a total of 48 months.  Some participants may receive a medical deferral as a result of an injury, a temporary medical condition, or other good cause reason.  However, if a participant is in deferred status, he/she continues to be subject to the cash assistance time limits.

•	I am requesting that my medical information be released to the Welfare Transition Program provider to help me develop my self-sufficiency plan.  To become self-sufficient, I will work with my career manager to overcome barriers to employment and/or seek medical/disability services.

•	My self-sufficiency plan may include participation in medical treatment, counseling, therapy, etc.

•	My plan may include employment, attending classes, studying at home, or volunteering at a worksite designed to meet my physical/mental health limitations.

•	Each time a new form is needed, I will sign a request for medical information authorizing the licensed physician to complete the form. 

•	The participant or legal guardian for participants under the age of 18 are the only representatives allowed to provide consent/request for information on the medical verification form. 

•	The release of medical information portion of the medical verification form is located on the next page. The release of medical information verifies that I have reviewed my rights and responsibilities regarding the release of my confidential health information with my career manager.  The release includes my rights and responsibilities as stated in the Health Insurance Portability and Accountability Act (HIPAA).

Thank you for taking the time to complete the medical verification form.  Please forward the completed form to my career manager at the below address/fax number.  If you prefer, you can release the paperwork back to me, and I can deliver the paperwork myself. 

Name: | | Phone Number: |
Address: | | Fax Number: |

Release of Medical Information

Participant’s Name: 						 Social Security Number: 
Birth date:  
I understand that I have given the physician permission to complete the medical verification form.  
•	I understand that the information will state my current diagnosis and possible limitations to engage in countable work activities.  By completing the medical form, I am requesting that my physician provide the information to the Welfare Transition Program (WTP) provider.
•	The information on the form will be used to develop a personalized self-sufficiency plan that takes my limitations, medical needs and treatment into consideration.  The completed form may also be used when considering an extension to my cash assistance time limits.

Rights
•	I have the right to refuse to sign the Release of Medical Information Form. Refusing to sign the form (alone) will not affect my benefits. 
•	The authorization of the Medical Verification Form may not condition medical treatment, payment, or enrollment.   
•	I understand that I have the right to revoke the authorization of this form.  To revoke the authorization, I must submit a request in writing to both the physician and the WTP provider.   I will have to provide the written request to both parties by the close of business (5 p.m.) on ________/________/________.   
•	Once the form is completed, the form will be included in my case file, but the information may not be used to determine limitations or medical inability after six months from the physician’s signature date. 
•	I have the right to privacy.  The medical verification form and information that is given in the form is confidential health information.  The WTP provider is the sole recipient of the information.  The information may be disclosed only in the course of official business and the verification of continued eligibility/compliance. 

Responsibilities

•	I have agreed to have the form completed and return the completed form to my career manager by (date)_________________________ at (time)___________________________.
•	If I refuse to sign the form or fail to supply the required information by the above date, I must participate in the Welfare Transition Program’s (WTP) countable activities for the minimum required hours unless another good cause reason is documented.
•	I must complete the activities as indicated on my self-sufficiency plan.  Refusal to sign the form and failure to participate in countable activities may result in the reduction or cancellation of my cash assistance and food assistance benefits.  
•	If I refuse to participate in the program and fail to complete the agreed upon activities listed in my self-sufficiency plan, my benefits may be reduced or cancelled. 
•	If the form is revoked, I am still responsible for completing the activities I agreed to complete on my self-sufficiency plan. 

I have reviewed my rights and responsibilities with my career manager. 
	
__________________________            __________________       	Expiration of Request is 60 days from signature date.
Signature of Participant		                        Date of Signature		  

__________________________________       	       ________________________        ______________________________
Signature of Guardian if under 18 years of age	        Printed Name of Guardian	 Date

MEDICAL VERIFICATION FORM TO BE COMPLETED BY LISCENSED PHYSICIAN

Name of Participant: 					Social Security Number:  

1.  What is the specific diagnosis of illness/injury of the participant?  _________________________________________

2.  A participant may still be able to work with limitations or be assigned to an activity that requires little physical strain or demand (attending classes, volunteer, home study, answering telephones, filing while seated).

	WORK	
a) Can (s)he “work” sitting down?  Yes      No   Only if frequent breaks are permitted ___________________ 
b)  Can (s)he “work” standing up?  Yes      No   Only if frequent breaks are permitted ___________________
c)  Are there other restrictions to him/her working?  Yes      No  
Restrictions:  _______________________________________________________________________________
d)  Are the number of hours (s)he can “work” limited?  Yes      No  
1-10 hours  11-20 hours  21-30 hours	 31-40 hours a week  or  Unable to “work” at all

VOLUNTEER
e) Can the (s)he volunteer hours? Yes      No   Only if frequent breaks are permitted ____________________
	Other limitations: ____________________________________________________________________________

SCHOOL
f) Can the (s)he go to school or go to classes?  Yes   No   Comments:___________________________________
	Are there limitations? _________________________________________________________________________

3.  Is this condition  permanent or  temporary?  If temporary, indicate estimated duration  ______# Months.  If this individual is pregnant, what is the expected date of delivery?  _____/_____/_____.

4.  Is (s)he required to attend physical therapy?    Yes   No   If yes, how often? _________________________________

5.  Is (s)he required to attend counseling appointments?   Yes   No   If yes, how often? ___________________________

6.  Is (s)he required to attend any other type of therapy or regular appointments?   Yes   No   If yes, how often? _______

7.   Date of patient’s most recent office visit:  _____/_____/_____

_________________________________           ______________________________________________    	       (____) ____-_______
^Name ^of ^Licensed ^Physician                                                           ^Signature ^of ^Physician: ^this ^form ^must ^be ^signed ^by ^a ^Licensed ^Physician.                       ^Telephone ^Number

^____________________________________________________________________________________________________________________________
^Mailing ^Address ^(include ^city ^and ^zip ^code)
______________________________________		________/________/_________
^Physician’s ^License ^Number ^(per ^Chapter ^458 ^or ^Chapter ^459, ^F.S.)	                      ^Date ^Form ^Completed

PRIVACY ACT STATEMENT

*I understand that I am required by law to provide my social security number(s) or proof that I have applied for a social security number if I do not currently have one to receive TANF funded benefits/services. This is mandatory under the Social Security Act (42 U.S.C. 1137). If I do not have a social security number and have not applied for a social security number, I can request help with filing an application. The social security number is used to administer the program, including determining eligibility, attributing the receipt of services, correspondence and participation to my case, as well as for reporting purposes.

DEO-WTP 2288(a), March 2013 (Replaces DEO-WTP 2288(a), October 2011)  				              		                 
Includes HIPPA language and requirements

An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers on this document may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.