Free 01111.FH11 - Indiana

DETERMINATION OF MEDICAID DISABILITY SOCIAL SUMMARY
State Form 1111 (R9 / 12-05) / OMPP 0251B

ALL 8 SECTIONS MUST BE COMPLETED.

CONFIDENTIALITY STATEMENT
The personal information requested on this form will be used in the determination of the applicant's entitlement to or continued receipt of Medical Assistance administered by the Office of Medicaid Policy and Planning. Disclosure by the applicant of the information requested is mandatory pursuant to the provisions of I.C. 12-15 et seq. Non-disclosure of the information requested will hamper and possibly prevent the delivery of assistance to the applicant. All personal information collected on this form will be treated as confidential pursuant to 470 IAC 1-2-7 and 470 IAC 1-3-1.

SECTION 1. IDENTIFYING INFORMATION
Name of applicant Case number Date of birth (month, day, year) Social Security number Application date (month, day, year)

SECTION 2. SOCIAL SECURITY INFORMATION
Has the applicant applied for: (a) Social Security Disability benefits? Yes No (b) Supplemental Security Income (SSI) benefits? Yes No If yes to (a) or (b) above, what is the status of the request? Effective date of denial: __________ Effective date of approval: __________ Application is pending: __________ (c) Does the applicant receive Retirement Survivors Disability Insurance (RSDI) based on disability?

Yes

No

SECTION 3. LIVING ARRANGEMENTS (Check One)
Applicant lives: Alone With spouse With parent With other relative With non-relative County Home Halfway House Nursing Home Group Home State Facility Homeless / Shelter

SECTION 4. MEDICAL HISTORY
(A) Applicant has the following physical and / or mental disability: DISABILITY DATE DISABILITY BEGAN

(B) Is the applicant currently under a doctors care? Yes No Address (number and street, city, state, ZIP code) Telephone number ( )

If yes, name of doctor

Page 1 of 3 pages

SECTION 4. MEDICAL HISTORY (continued)
(C) Has the applicant received a physical exam in the past 3 months? Yes No Address (number and street, city, state, ZIP code) Telephone number ( ) (D) Medical and psychological treatment within the past 12 months. (List only those medical sources / providers related to the disabilities given on page 1 section 4A of this form) This table cannot be left blank - fill it in or write the word NONE. FULL NAME AND ADDRESS OF DOCTOR, PSYCHIATRIST, HOSPITAL, CLINIC, INSTITUTION, MENTAL HEALTH AGENCY OR OTHER DATE(S) OF MOST RECENT CARE REASON FOR VISIT If yes, name of doctor

(E) Applicant is taking the following medications (correct spelling and dosage is important) / treatments / therapies: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

SECTION 5. FUNCTIONAL LIMITATIONS
Applicant states the disability limits performance in the following areas (examples: lifting, walking, bending, sitting, driving, etc.)

Applicant uses the following devices for walking / moving around: (check all that apply) Cane Walker Crutches Wheelchair Braces (what type): ___________________________________

SECTION 6. EDUCATION
Highest grade completed: ____________ (a) High School Diploma received: Yes (b) GED received: Yes Attended College: Yes No Attended Technical School: Yes No Received Special Education: Yes No Is applicant able to read? Yes No

No No Number of years: Type: Grades:

Date: ____________ Date: ____________

Is applicant able to write? Yes No Page 2 of 3 pages

Is applicant able to speak English? Yes No

SECTION 7. EMPLOYMENT AND VOCATIONAL REHABILITATION
Is applicant currently working? Yes No Are there any special working conditions based solely upon disability? If yes, describe:

If applicant is not currently working but has worked in the past, what is the title of the job performed? Please check one of the following regarding the applicants work history: Manual labor only Clerical or Sedentary Sheltered Workshop Job Coach Unable to Keep Jobs Never Employed Reason:

Date last worked (month, day, year)

Vocational Rehabilitation:
Is the applicant currently receiving vocational rehabilitation? Yes No Has the applicant received vocational rehabilitation in the past? If yes, when? Yes No

SECTION 8. CASEWORKERS SUMMARY (Very important to complete.)
(a) Appearance: (Describe what you see - discuss items like dress, hygiene, presentation)

(b) Medical: (Describe what you see and hear relating to the applicants disability - physical difficulties)

(c) Psychological / Social: (Describe what you notice during the interview - does the applicant see things that are not there? Hear voices? Talk about suicide? Use drugs or alcohol? Understand your questions? Communicate with you in an understandable way? Is someone else assisting the applicant with the interview?)

(d) Other : (For comments on anything that doesnt fit in the above areas)

Name of caseworker completing this form How was interview conducted? In person

By telephone

Application was taken by a professional service Page 3 of 3 pages