DSHS MAILING ADDRESS DSHS, PO BOX 11699 ABLE-BODIED ADULTS WITHOUT DEPENDENTS (ABAWD) ABAWD Requirement: TACOMA WA 98411-9905 Medical Report DSHS PHONE NUMBER DSHS FAX NUMBER ( ) 888-338-7410 CASE / CLIENT ID NUMBER Please use blue or black ink. Section 1. To be filled out by the client CLIENT NAME (PLEASE PRINT) SOCIAL SECURITY NUMBER (OPTIONAL) Patient / Client participant’s authorization: I authorize the release of medical information and/or rehabilitation participation requested to the Department of Social and Health Services. PATIENT / CLIENT DATE PARTICIPANT’S SIGNATURE Section 2. To be filled out by a medical professional ** 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 this 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 individual have a mental and/or physical illness or disability, temporary or permanent, which would prevent them from working 20 hours a week? Yes No If yes, please indicate the how long their condition would prevent them from working 20 hours a week: Less than 30 days 1 3 months 3 6 months – – 6 9 months 9 12 months More than 12 months or indefinite – – I certify the information provided above is true and accurate. SIGNATURE DATE SIGNED PHONE NUMBER (WITH AREA CODE) ( ) PRINT NAME HERE TITLE / PROFESSION** ADDRESS CITY STATE ZIP CODE
ABLE-BODIED ADULTS WITHOUT DEPENDENTS (ABAWD) ABAWD Requirement: Medical Report Please use blue or black ink. DSHS MAILING ADDRESS DSHS, PO BOX 11699 TACOMA WA 98411-9905 DSHS PHONE NUMBER ( ) DSHS FAX NUMBER 888-338-7410 CASE / CLIENT ID NUMBER Section 1. To be filled out by the client CLIENT NAME (PLEASE PRINT) SOCIAL SECURITY NUMBER (OPTIONAL) Patient / Client participant’s authorization: I authorize the release of medical information and/or rehabilitation participation requested to the Department of Social and Health Services. PATIENT / CLIENT PARTICIPANT’S SIGNATURE DATE Section 2. To be filled out by a medical professional ** 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 this 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 individual have a mental and/or physical illness or disability, temporary or permanent, which would prevent them from working 20 hours a week? Yes No If yes, please indicate the how long their condition would prevent them from working 20 hours a week: Less than 30 days 1 – 3 months 3 – 6 months 6 – 9 months 9 – 12 months More than 12 months or indefinite I certify the information provided above is true and accurate. SIGNATURE DATE SIGNED PHONE NUMBER (WITH AREA CODE) ( ) PRINT NAME HERE TITLE / PROFESSION** ADDRESS CITY STATE ZIP CODE