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

Name Of Physician | | Date

Dear Physician,

I, (patient’s name) _________________________________________, am requesting that the attached Statement of Need for Care form be completed.  This form or other medical documentation verifying caretaker status must be completed by a physician licensed under Florida Statute Chapters 458 and/or 459.

•	My family member __________ is taking care of me due my illness, injury and/or disability. 

•	My family member is currently in a workforce program, which prepares families for self-sufficiency.  In order to receive cash assistance, recipients are required to participate in countable work activities.    Some cash recipients may receive a temporary medical excuse from some or all program requirements while caring for a disabled family member or other good cause reason.  

•	My family member, as a part of the workforce program, would like to develop a self-sufficiency plan that considers his or her caretaker role. Because he or she is caring for me, the Statement of Need for Care Form needs to be completed.

•	The only representative allowed to request the information on the Statement of Need for Care form is the individual requiring care (if adult over the age of 18), the legal guardian for the individual that is requiring care who is under the age of 18 or the legal representative of the individual requiring care.

•	The individual requiring care (patient) or the legal guardian of a child under the age of 18 requiring care is the only person allowed to request the completion of the Statement of Need for Care form.  Each time a new form is needed, a new release will be signed.

•	I have signed a medical release of information.  My family member has also signed the rights and responsibilities portion of the form.  Both releases are attached. 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 Statement of Need for Care form. Please forward the completed form to the following career manager; or if you prefer, please give me the form so that I can deliver it to the career manager:

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

Welfare Transition Participant Rights and Responsibilities

Part I. To be Completed by WT Program Participant,  

*Social Security Number: 

Mr./Ms ___________(the WT participant) has stated that he or she is caring for a family member full or part-time.
Name of the family member requiring care (patient’s name) ______________________________________________.
The WT participant’s relationship to the family member in need of care/patient _______________________________.
The family member in need of care  is a household member or  is not a household member of the WT participant. 

I provide care for  1-10 hours a week,  11-20 hours a week,  21-30 hours a week,  31-40 hours a week.
  Other (example, I can participate in the program, but drive my family member to appointments three (3) times a week, etc) ______________________________________________________________________________________________

______________________________________________________________________________________________.

 I certify that there is no one else to care for or assist my disabled family member. 

Rights
•	I have agreed to have the statement completed.  If I change my mind and want to revoke the process of having the statement completed, I must submit a request in writing to both the physician and the WT program provider.  I must provide the written request to both parties by the close of business (5 p.m.) on ________/________/________.   
•	I have the right to withdraw my role as a caretaker. I must inform my career manager immediately when the circumstances change so that I can update my self-sufficiency plan.

Responsibilities
•	I understand that the form must be completed by the physician and turned into 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 WT program’s countable activities for the minimum required hours.
•	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 my cash assistance and food stamp benefits.  
•	If the form is revoked, I am still responsible for completing the activities I agreed to complete on my self-sufficiency plan. 

__________________________            __________________      	
Signature of WT Participant		                        Date of Signature		  

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

Physician Statement

Part II. To be signed by the disabled family member if over the age of 18:  or to be signed by the parent or legal guardian/legal representative if under the age of 18 or unable to complete the form. 

I ______________________ (the individual that is in need of care/patient) understand that I have given the physician permission to complete the Statement of Need for Care form. 
•	I, the patient, understand that the information will state my current diagnosis.  In doing so, I am authorizing my physician to provide information to the Welfare Transition (WT) program staff. 
RIGHTS
•	I, the patient, have the right to refuse to sign the release of information. Refusing will not affect or condition medical treatment, payment, or enrollment. 
•	I, the patient, understand that I have the right to revoke the authorization of this form. 
•	I, the patient, have the right to privacy. The Statement of Need for Care form and information that is given in the form is confidential health information. The WT 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
•	To revoke the authorization, I, the patient, must submit a request in writing to both the physician and the RWB provider. I must provide the written request to both parties by the close of business (5:00 pm) on _______/_______/_______.   

I, (patient’s full name)_____________________________, authorize the release of my medical information to the WT program provider. I request that Dr. __________________________ complete the Statement of Need for Care Form regarding my medical condition.   My birth date is _________________________________.  

________________________________	_________________	 _______________	____________________                                                          
^Print ^Name ^of ^Individual ^Receiving ^Care			^Signature		 	   ^Date 			  ^Phone ^Number
________________________________	_________________	 _______________	_____________________
^Print ^Name ^of ^Legal ^Representative 			^Signature		 	  ^Date			  ^Phone ^Number
^(individual ^cannot ^sign ^form)

________________________________	_________________	 ________________	_____________________
^Print ^Name ^of ^Parent ^or ^Legal ^Guardian			^Signature			  ^Date			 ^Phone ^Number
^(if ^person ^receiving ^care ^is ^under ^age ^18)

The expiration of the signature to release the protected health information is 90 days from date signed. 

Part III. To be completed by a physician licensed under Florida Statute Chapters 458 and/459. 

1. This certifies that (patient’s name) ____________________________ has a primary diagnosis of _______________
___________________________________________________________________________________________.
2. The condition is  permanent or  temporary?
3. This individual, (patient’s name) _________________________________, is required to have part-time care or         full-time care. 
a) Part-time care:
The individual must be cared for during the following hours __________________________________________.  
 The individual needs assistance getting to medical appointments or is requiring assistance during specific planned treatment.  Comments: __________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________.
 The part-time care began on or about _________________________________ and may last through 
___________________________.  Comments: _____________________________________________________
___________________________________________________________________________________________.
b) Full-time care:
The need for full-time care began on or about _______________________________ and may last through _________________________________.  Comments: _______________________________________________

________________________	_________________________	(____) _________________________
^Name ^of ^Licensed ^Physician			^Signature ^of ^Physician				^Telephone ^Number

___________________________________________________________________________________________
^Mailing ^Address ^(include ^city ^and ^zip ^code)

________________________________________________________ 	_______________________________
^Physician’s ^License ^Number								^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 2288b, March 2013 (Replaces DEO-WTP 2288b, October 2011)

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.