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Printable utah state functiona... FUNCTIONAL ABILITY EVALUATION MEDICAL REPORT UTAH DRIVER LICENSE DIVISION TOP PORTION MUST BE COMPLETED BY APPLICANT - Please use BLACK ink Fax Number 801 957-8698 www. I also understand that I may revoke this authorization at any time by sending written notification to the Utah Driver License Division at the above address. I understand that if I fail to sign this authorization my driving privilege may be affected. I understand that this informat...

This is the only medical repor... Department of the Secretary of State Bureau of Motor Vehicles WORK-RESTRICTED DRIVER'S LICENSE PETITION Applies to Class C, Non-Commercial Driving Privileges Only ***You must submit your license and

Medical report disability supp... Medical Report Disability Support Pension Customer s details Full name Address / Date of birth Phone number Your Centrelink Reference Number This information will help the Australian Government Department of Human Services in determining income support eligibility if the customer may benefit from a program of assistance or training Instructions for the customer Information for the doctor 1 Complete your details above. 2 Contact your doctor or medical specialist and make an appointment to have the Medical Report completed* Make sure the doctor and their receptionist know that you will need this report completed as a long consultation may be required* If your doctor does not bulk bill your consultation fee may be more than usual because of the extra time taken to complete the report. Important information A doctor or medical specialist is a person registered and licensed under a state or territory law that provides for the registration or licensing of medical practitioners. It includes only those with recognised medical qualifications such as general practitioners and medical specialists and excludes those with non-medical qualifications e*g* psychologists or physiotherapists. Note If a person has an intellectual impairment and this is their only condition the Medical Report can be completed by the person s treating psychologist. 3 Attend the appointment with your doctor or medical specialist. Completing this report You can complete and lodge Medical Reports electronically through Health Professional Online Services HPOS. For more information go to our website humanservices. gov*au/healthprofessionals and logon to HPOS* In this report you will be asked to provide information about your patient s medical condition s. Please complete all the required questions in this report. If you require another paper copy of the Medical Report go to our website humanservices. gov*au/forms If you need more information in order to complete the Medical Report call us on 132 150. www. Returning this report You can give this report and any attachments to your patient or you can return it to Department of Human Services Disability Services Reply Paid 7806 CANBERRA BC ACT 2610 Continued 4 When your doctor or specialist has completed this Medical Report it must be returned to us. 5 If you have other relevant information such as specialist medical reports or an assessment of your intellectual function showing your IQ score if relevant to your claim return them to us with this report. CLK0SA012 1311 SA012. 1311 1 of 11 Important This request is a notice given under section 63 of the Social Security Administration Act 1999. Request for clarification of additional information Human Services including staff from the Health Professional Advisory Unit may make contact with you to discuss the information in your report. These contacts will only occur where information requires clarification* Privacy and your personal information Your personal information is protected by law including the Privacy Act 1988 and is collected by the Australian Government administration of payments and services.

Imm 1017 form Fillable Form Citizenship and Immigration Canada Citoyennet et Immigration Canada PROTECTED WHEN COMPLETED - B FOR OFFICIAL USE ONLY CASE PROCESSING CENTRE - VEGREVILLE IMS Serial Number: FOSS Client

Medical report blank page form Items 62 - 71 ... DD FORM 2808, AUG 2000. Page 1 of 3 Pages. CLINICAL EVALUATION (Check each item in appropriate ...

Imm 1017b form pdf OP 15 Medical Procedures Updates to chapter .................................................................................................................... 4 1. 2. 3. 3.1. 4. 4.1. 5. 5.1. 5.2.

Eaedc medical report form 2009 Follow these steps Fill out this Medical Records Release Form before you give the EAEDC Medical Report to your medical and mental health care provider. Call UMASS/Disability Evaluation Services DES at 1-800-888-3420 with questions you may have regarding the completion of this report. EAEDC-Med Rpt Rev. 5/2009 04-012-0509-05 Blank Page Department of Transitional Assistance DTA and Disability Evaluation Services DES Medical Records Release Form Sign this form to let your medical and mental health care provider share information with UMASS/Disability Evaluation Services DES. PATIENT INFORMATION Last Name Date of Birth First Name Social Security Number Address Street City State Zip Code Telephone Number Massachusetts Department of Transitional Assistance EAEDC Medical Report General Instructions to Medical and Mental Health Care Providers Your patient has applied for cash and medical assistance under a DTA program as disabled* To be eligible your patient must file an EAEDC Medical Report so that eligibility can be determined* Regulations for a disability determination require that a diagnosis be supported by specific clinical findings. The medical data provided by you in the report clinical findings diagnosis test results will be used by DTA to determine disability. For these purposes an individual is disabled if he or she has an impairment or combination of impairments that is expected to last 60 days or more and that substantially reduces or eliminates the applicant s or recipient s ability to support himself or herself* If you need a copy of DTA s regulations regarding a disability determination telephone 617 348-5299 and leave a message or refer to DTA s regulations by visiting the Mass. gov website at http //www. mass. gov/Eeohhs2/docs/dta/greg320. pdf The Department will pay for the medical evaluations needed to complete a Medical Report including diagnostic tests through its regular medical billing system MMIS. Please use your regular MassHealth Provider Number when submitting invoices for these services. The EAEDC Medical Report must be signed by a Competent Medical Authority. Please refer to page 7 for details before proceeding further. functioning. It is essential that when you complete the EAEDC Medical Report you supply all relevant information* Complete the EAEDC Medical Report in full with respect to the conditions that are relevant to the patient. Sign and return it to the patient or mail it to the DTA Transitional Assistance Office indicated on page 8. Call UMASS/Disability Evaluation Services DES at 1-800-888-3420 with questions you may have regarding the completion of this report. EAEDC-Med Rpt Rev* 5/2009 04-012-0509-05 Blank Page Department of Transitional Assistance DTA and Disability Evaluation Services DES Medical Records Release Form Sign this form to let your medical and mental health care provider share information with UMASS/Disability Evaluation Services DES. HOW TO FILL OUT THIS FORM Your medical and mental health care provider will only send medical records to UMASS/Disability Evaluation Services if you fill out the form right.

Functional ability evaluation... FUNCTIONAL ABILITY EVALUATION MEDICAL REPORT UTAH DRIVER LICENSE DIVISION TOP PORTION MUST BE COMPLETED BY APPLICANT - Please use BLACK ink Fax Number: 801 957-8698 www.driverlicense.utah.gov P O

Sp medical report form singapo... Medical Report Form MEDICAL REPORT (2014) Admission Number (This medical report will not be returned to the student) This form may take you 3 minutes to fill. The data provided will be kept strictly

Child care provider medical re... STATE OF TENNESSEE DEPARTMENT OF HUMAN SERVICES CHILD CARE PROVIDER MEDICAL REPORT A. TO BE COMPLETED BY PROVIDER Name Birth Date Address Street City State Zip Code I hereby authorize the physician s name below to release information Provider/Patient s Signature to the Department of Human Services for approval/licensure or employment as a child care provider. Address Name of Physician s Purpose of Examination Initial Employment Type of Activity In Child Care check all that apply Caregiver Food Preparation Driver Facility Maintenance Other Re-examination 1. How long have you known this patient or have had knowledge of their medical history 2. In your opinion does this person have a* The ability to lift 40 pounds b. The agility to move quickly to keep pace with toddlers c* The stamina to remain alert and energetic for 8 hours or more d. Any condition which requires restriction of activity or which could affect patient s temperament and interaction with children If so explain in Number 3 YES NO 3. Specify any physical mental or emotional limitation affecting this person s ability to care for a group of children* 4. Is this patient currently taking any medications which could affect their work role or interaction with children Yes No If yes please explain 5. Address Name of Physician s Purpose of Examination Initial Employment Type of Activity In Child Care check all that apply Caregiver Food Preparation Driver Facility Maintenance Other Re-examination 1. How long have you known this patient or have had knowledge of their medical history 2. In your opinion does this person have a* The ability to lift 40 pounds b. How long have you known this patient or have had knowledge of their medical history 2. In your opinion does this person have a* The ability to lift 40 pounds b. The agility to move quickly to keep pace with toddlers c* The stamina to remain alert and energetic for 8 hours or more d. The agility to move quickly to keep pace with toddlers c* The stamina to remain alert and energetic for 8 hours or more d. Any condition which requires restriction of activity or which could affect patient s temperament and interaction with children If so explain in Number 3 YES NO 3. Any condition which requires restriction of activity or which could affect patient s temperament and interaction with children If so explain in Number 3 YES NO 3. Specify any physical mental or emotional limitation affecting this person s ability to care for a group of children* 4. Specify any physical mental or emotional limitation affecting this person s ability to care for a group of children* 4. Is this patient currently taking any medications which could affect their work role or interaction with children Yes No If yes please explain 5. Address Name of Physician s Purpose of Examination Initial Employment Type of Activity In Child Care check all that apply Caregiver Food Preparation Driver Facility Maintenance Other Re-examination 1. How long have you known this patient or have had knowledge of their medical history 2. In your opinion does this person have a* The ability to lift 40 pounds b. The agility to move quickly to keep pace with toddlers c* The stamina to remain alert and energetic for 8 hours or more d.

Carer payment and carer allowa... Print Instructions Clear Carer Payment and Carer Allowance Medical Report (for a child under 16 years) Childs details You will need to provide a separate report for each child contact us if you require

Medical fitness report form DOT MEDICAL CERTIFICATE I certify I have examined: in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.49) and with knowledge of the driving duties, I find this person qualified,

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