ࡱ>  bjbj *!SSSSSggggcg2Ct     z!0&n)dBBBBBBBDHGBS*X!"z!**BSS  QB616161*RS S B61*B6161?h@ Y7Ag$+j?BC02C@G+G @GS@<**61*****BB.***2C****G********* :  MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION SOCIAL INFORMATION SUMMARY CASE NAME (FIRST)  FORMTEXT      (MIDDLE)  FORMTEXT       (LAST)  FORMTEXT       CASE DCN  FORMTEXT      COUNTY  FORMTEXT      INDIVIDUAL NAME (FIRST)  FORMTEXT       (MIDDLE)  FORMTEXT        FORMTEXT (LAST)  FORMTEXT      INDIVIDUAL DCN  FORMTEXT      DATE OF BIRTH (MONTH)  FORMTEXT       (DAY)  FORMTEXT      (YEAR)  FORMTEXT      ELIGIBILITY SPECIALIST  FORMTEXT      WORKER NUMBER/FAMIS USERID  FORMTEXT      LOAD  FORMTEXT      DATE OF APP/REAPP  FORMTEXT      DATE SUBMITTED TO MRT  FORMTEXT      CASE STATUS OF DISABLED PERSON (CHECK ONLY LIVING ARRANGEMENT (CHECK ANY THAT APPLY)PROGRAMS FOR WHICH YOU WANT MEDICAL dECISION)1. APPLICATION2. REDETERMINATION MA NC TA TWHA  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  PQ  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   MHABD NC SP TA TWHA   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX PQ  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  ALONE  FORMCHECKBOX  WITH UNRELATED PERSON(S)  FORMCHECKBOX  WITH FAMILY GROUP  FORMCHECKBOX  IN NURSING HOME/  FORMTEXT    NO. ADULTS INSTITUTION  FORMTEXT    NO. CHILDREN (UNDER 18)ASSISTANCE HISTORY OF INDIVIDUALPROGRAMDATES RECEIVEDPAYEEOTHERREASON LAST CLOSED FORMTEXT       FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT       FORMTEXT       FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT       FORMTEXT       FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT       FORMTEXT       FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT      WORK HISTORY (LAST 10 YEARS, INCLUDE MILITARY SERVICE)DATES FROM/TOFULL TIMEPART TIMEEMPLOYERTYPES OF WORK JOB DUTIES/ACTIVITIESPARTICIPANT STATEMENT OF GROSS MO INCOMEGROSS MO INCOME VERIFIED BY WORKERREASON FOR LEAVING FORMTEXT      - FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT      - FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      - FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      - FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      IS PARTICIPANT EMPLOYED AT A SHELTERED WORKSHOP?  FORMCHECKBOX  YES  FORMCHECKBOX  NOIF YES, DOES PARTICIPANT FEEL THEY ARE OVERPAID FOR THEIR WORK?  FORMCHECKBOX  YES  FORMCHECKBOX  NO IF YES, EXPLAIN:  FORMTEXT       EXPENSESDOES THE PARTICIPANT HAVE MEDICAL EXPENSES (ITEMS AND SEERVICES) NEEDED TO ENABLE HIM/HER TO WORK? (EX: MEDICAL DEVICES, ATTENDANT SERVICES, TRAVEL TO WORK, PROSTHESIS)  FORMCHECKBOX  YES  FORMCHECKBOX  NO IF YES, LIST THE EXPENSE(S) AND THE AMOUNT(S) BELOW.TYPE OF EXPENSEEXPENSE AMOUNT CLAIMED BY PARTICIPANTEXPENSE AMOUNT VERIFIED BY WORKER FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      RECORD OF TREATMENTTREATING PHYYSICIAN 1  FORMTEXT      ADDRESS  FORMTEXT      DATE LAST SEEN  FORMTEXT      TREATING PHYSICIAN 2  FORMTEXT      ADDRESS  FORMTEXT      DATE LAST SEEN  FORMTEXT      HOSPITALIZATION 1-HOSPITAL NAME  FORMTEXT      ADDRESS  FORMTEXT      DATE OF LAST ADMISSION  FORMTEXT      HOSPITALIZATION 2- HOSPITAL NAME  FORMTEXT      ADDRESS  FORMTEXT      DATE OF LAST ADMISSION  FORMTEXT      EXPLAIN  FORMTEXT           , . 0 : < > @ N P d f h r t v x   0 ܸܭܢܗܑh0Ljh0LU huCJ jh+iUjgh+iUjah+iUj[h+iUjh+iUmHnHujUh+iUh+ijh+iU h+iCJ h2= 5h2= jh2= U0R  > @ N v x d$If $If^gd+i $If^d,&#$+D/  B \ vll_____V $Ifgd' p$If^pgd' $If^kd$$IfH rE"+  P,4 HaytM! 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For all other participants proceed to Step 2. Step 1: Does the participant have a severe impairment which is considered to significantly limit his/her physical or mental ability to do basic work activities? No. The person is ineligible for MHABD on this basis. Proceed to Step 2 to determine eligibility for TWHA if participant has earned income. Yes. Proceed to Step 2. Step 2: Does the participant s impairment meet or equal a Social Security disability listing? Yes. The participant is eligible for MHABD or TWHA. No. Proceed to Step 3. Step 3: Does the participant s impairment prevent the participant from doing past, relevant work? No. The participant can still do the kind of work s/he has done in the past and is not eligible for MHABD. Yes. Proceed to Step 4. Step 4: Does the participant s impairment prevent the claimant from doing other work considering the participant s age, education, and past work experience? No. The participant can do other work for which his/her age, training, and work history has fitted him/her and is ineligible for MHABD. Yes. Participant meets the criteria set forth in 20 CFR Section 416.962, medical-vocational profiles showing an inability to make an adjustment to other work, which states:  (a) If you have done only arduous unskilled physical labor. If you have no more than a marginal education& and work experience of 35 years or more during which you did only arduous unskilled physical labor, and you are not working and are no longer able to do this kind of work because of a severe impairment(s), we will consider you unable to do lighter work and, therefore, disabled. Example to paragraph (a): Mr. B is a 58-year-old miner s helper with a fourth grade education who has a lifelong history of unskilled arduous physical labor. Mr. B says that he is disabled because of arthritis of his spine, hips and knees, and other impairments. Medical evidence shows a  severe combination of impairments that prevents Mr. B from performing his past relevant work. Under these circumstances, we will find that Mr. B is disabled. (b) If you are at least 55 years old, have no more than a limited education, and have no past relevant work experience: If you have a severe, medically determinable impairment(s)& , are of advanced age (age 55 or older)..., have a limited education or less, and have no past relevant work experience& , we will find you disabled. If the evidence shows that you meet this profile, we will not need to assess your residual functional capacity&  The individual is eligible for Medical Assistance. I have followed the four-step sequential evaluation process for evaluating disability as outlined in 20 CFR Section 416.920; this is established by my entries on this document. WE HAVE REVIEWED THE MEDICAL REPORTS AND SOCIAL INFORMATION AND CERTIFY THIS INDIVIDUALA. ELIGIBLE FOR:DATE NEXT REVIEWB. INELIGIBLE FOR:INFORMATION INSUFFICIENT FOR:PQPQ FORMCHECKBOX  MHABD/NC/SP/TWHA FORMCHECKBOX  FORMTEXT       FORMCHECKBOX  MHABD/NC/SP/TWHA FORMCHECKBOX  FORMCHECKBOX  MHABD/NC/SP/TWHA FORMCHECKBOX  TA FORMTEXT       FORMCHECKBOX  TA FORMCHECKBOX  TAC. PRIMARY DIAGNOSIS/DISABILITY/RECOMMENDATIONS  FORMCHECKBOX  REFER TO VOCATIONAL REHABILITATION (VR)  FORMTEXT       MRT PHYSICIAN  DATE  MRT SUPERVISOR DATE MO 886-0735 (07-09) IM-61 *68:<>$IfMkd$$Ifl0Ed+1P,4 laytD2 $$Ifa$ $If^gd[1$Ifvkd$$IflL+p,  t 044 lap ytM!&zƪȪ||ssf & F$IfgdM! $Ifgd0p & F$IfgdM! p$If^pgdM!hkd$$IflpL+p, t044 laytM! 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