Free 01380.FH11 - Indiana

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Date: October 16, 2008
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State: Indiana
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DETERMINATION OF MEDICAID DISABILITY Authorization for Release of Medical Information
Return form and records to:

Page 1 of 7 pages

State Form 1380 (R12 / 6-08) / OMPP 0251A Prescribed by the Indiana Family and Social Services Administration, Office of Medicaid Policy and Planning

County DFR

Address (street address or Rural Route number and city, state, and ZIP code)

CONFIDENTIALITY STATEMENT The personal information requested on this form will be used in the determination of your entitlement to or continued receipt of Medical Assistance administered by the Indiana Family and Social Services Administration. Disclosure of the information requested is mandatory pursuant to the provisions of IC 12-15 et seq. Non-disclosure of the information requested will hamper and possibly prevent the delivery of assistance to you. 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, 42 CFR 431 Subpart F and 45 CFR 164 Subpart E and 42 CFR Part 2. NOTICE TO EXAMINING PHYSICIAN By court order and federal regulation, if the client appeals the decision of the State Medicaid Medical Review T eam, this medical information becomes available to the client or his/her legal representative. DETERMINATION OF DISABILITY: Medical Information Indiana Law [IC 12-14-15-1(2)] requires that, in order to be eligible for Medical Assistance to the Disabled, a person must have a physical or mental impairment, disease, or loss which appears reasonably certain to result in death or appears reasonably certain to last for a continuous period of at least twelve (12) months without significant improvement and which substantially impairs his/her ability to perform labor or services or to engage in a useful occupation. This is not the same definition of disability that is used by the Social Security Administration, or other agencies.

The law [IC 12-14-15-1 (2) and IC 25-22-5] requires an individual to be examined by a physician holding an unlimited license to practice medicine. The Medicaid Medical Review T eam will make the final disability determination. The records released pursuant to this authorization will be used in making this determination.
SECTION I - IDENTIFICATION (to be completed by County Office, Division of Family Resources)
Name (first, middle, last) Address (street address or Rural Route number and city, state, and ZIP code) Date of birth (month, day, year) Case number

Date of birth of patient/applicant (month, day, year) Social Security number of patient/applicant Case number

Date of consent (month, day, year)


First name

Middle initial Address (number and street, city, state, and ZIP code)

Last name

do hereby authorize

Name of person releasing information Organization releasing information Address of organization (number and street, city, state, and ZIP code)

to release the following medical records: Entire medical record for the following dates (month, day, year) Portions of the medical record relating to psychiatric, psychological, or mental health counseling for the dates specified above Portions of the medical record relating to alcohol, drug, or other substance abuse treatment for the dates specified above Portions of the medical record relating to any communicable or venereal disease which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus (HIV), also known as Acquired Immune Deficiency Syndrome (AIDS); and tests for HIV for the dates specified above Copies of the records should be furnished to the:
Name of local office

Address of local office (number and street, city, state, and ZIP code)

I understand that this information is protected under Federal and State confidentiality and privacy regulations and cannot be disclosed without my written authorization unless otherwise provided for in the regulations. I understand that, pursuant to IC 16-39-1-4, this consent for release of medical and mental health information is subject to revocation by me at any time, except to the extent that action has been taken in reliance on the consent. By law this consent might normally expire sixty (60) days from the consent date listed above; however, I expressly waive this time limit and consent to release of medical and mental health information for one (1) year from the consent date. This consent may be revoked in writing by contacting the county office listed above.
Signature of applicant or legal representative If patient is a minor, signature of parent or legal representative Date signed (month, day, year) Date signed (month, day, year)

State Form 1380 (R12 / 6-08) / OMPP 0251A Case number

Page 2 of 7 pages

SECTION III - REPORT OF MEDICAL EXAMINATION Complete only those sections pertinent to a description of substantial impairment. A. Current Medical History (Include the patient's complete medical history for at least 12 months. Attach additional sheets if necessary)
How long has the patient been treated by you? Please list all diagnostic tests and/or evaluations performed on the patient and their results.

Please list all treatments performed to-date relative to his / her impairment(s)

What are the patient's current medications including dosage and frequency?

Is the patient compliant with medications and treatment? If No, please explain.

State Form 1380 (R12 / 6-08) / OMPP 0251A Case number

Page 3 of 7 pages

B. Current Medical Evidence
Height Weight




Fasting blood sugar test (required if diagnosis is diabetes) Blood data (CBC if available) Eyes (degree of impairment of vision, if any)

OS _________________________ OD _________________________
Ears (degree of impairment of hearing, if any)

AS _________________________ AD _________________________
Nose, throat, mouth (describe abnormalities)

Neck and lymphatic system (describe abnormalities)

Cardiovascular System Blood Pressure
Murmurs? Systolic Diastolic Rhythm Pulse rate Degree of decompensation Cardiac enlargement? If Yes, degree

Yes Yes No
If Yes, when?

Is there auricular fibrillation?

Angina pectoris?

No No

Ever on digitalis?

Yes Yes
Ever on antihypertensive drugs?

If Yes, date occurred If Yes, when? Response Edema?


Evidence of past myocardial infarction?

No No
Cyanosis? Type of heart disease (please use A.H.A. classification)








If cardiac disease, attach current EKG, treadmill, catheterization or other interpretations.
Condition of palpable arteries Varicosities

Chest: Normal?
Describe abnormalities



If No, complete the rest of this section.


Frequency of attacks


Medication Pulmonary obstructive disease?









If chest disease, describe and attach current x-ray report

If emphysematous, send pulmonary function test results.

State Form 1380 (R12 / 6-08) / OMPP 0251A Case number

Page 4 of 7 pages

Nervous System: If the disability determination is to be based upon any of the following, enter a brief explanation of the degree of deterioration and attach appropriate evidence.
Organic (describe senility, tremors, atrophy, speech problems, gait, paralysis, epilepsy)

Non-Organic (describe evidence of psychosis or other mental disorder, including functional restrictions of daily activities and interests, the deterioration in personal habits and ability to relate to other persons)

Please indicate whether you recommenda psychological/psychiatric mental status evaluation



If Yes, briefly state the reason(s) for your recommendation, including a description of mental status, defects or problems (if applicable)

Mental Deficiency: This section must be completed if there is a diagnosis of mental retardation.
Full scale I.Q. Or estimated mental age Is the patient mentally capable of handling his/her own affairs?

Yes Musculo - Skeletal System: Bones, joints and extremities normal? Yes No
If No, describe disease, defect or injury and state limitation of motion. Attach x-ray report, if available




Describe deformities


State Form 1380 (R12 / 6-08) / OMPP 0251A Case number

Page 5 of 7 pages




If Yes to Metastasis, location (explain) - Please give clinical stage, if known.




Describe abnormalities



Yes No Genito - Urinary: (describe abnormalities)

Gynecological: (describe abnormalities)

Ano - Rectal: (describe abnormalities)

1. List below the patient's present diagnoses and your prognosis after treatment, of each disorder. Indicate if the disorder can be controlled, resolved, or improved by treatment. PLEASE INDICATE PRIME DIAGNOSIS(ES) FIRST. Diagnosis Date Began Date Condition Began Affecting Ability To Perform Labor/Services Prognosis After Treatment






State Form 1380 (R12 / 6-08) / OMPP 0251A Case number

Page 6 of 7 pages

2. Does the patient's impairment(s), taken together or individually, currently affect his/her ability to perform labor or services or engage in a useful occupation? If so, is the patient's inability to work temporary or is it likely to continue? What is the basis for this conclusion?

3. Is additional consultation or diagnostic evaluation / testing necessary to clarify the degree of impairment? If so, please specify the type of consult / exam / test required. Additional testing / exams may only be performed if prior-authorized by the Medicaid Medical Review Team physician. In order to request prior authorization, please call (317) 234-2107.

4. What are the standard treatment options to correct, improve or control the patient's condition(s)?

Do medical reasons prevent standard treatment options? (If Yes, please explain) Yes No

Is it expected that the patient's functional limitations will improve with regular medical care and / or the treatment options listed above? Yes No a. If the functional limitations will improve, please explain: How will they improve?

Are they expected to improve enough to enable the person to perform labor or services or engage in a useful occupation? Yes No If Yes, how long is the duration of the limitation expected to last before the patient is able to perform labor or services or engage in a useful occupation? 0-under 1 year 1-2 years 3-4 years greater than 4 years b. If the functional limitations are not expected to improve, please explain: Why will they not improve?

Are the limitations substantial enough to impair the individuals ability to perform labor or services or engage in a useful occupation? Yes No

State Form 1380 (R12 / 6-08) / OMPP 0251A Case number

Page 7 of 7 pages

5. Capacity and Limitations
Can the patient currently carry out normal activities? Yes No If No, specify, using the list below, how his/her condition affects activities or mobility by checking off the degree of severity as either not significant, moderate or significant. Please indicate in column 4 below whether the limitations are expected to continue even after regular medical care and / or treatment options as listed in Question 4 have been explored. LIMITATIONS ACTIVITY NOT SIGNIFICANT MODERATE SIGNIFICANT WILL LIMITATION CONTINUE AFTER TREATMENT? NO YES

Sitting Standing Walking Lifting Grasping / Manipulation Pushing / Pulling Bending Squatting Crawling Climbing Reaching Above Shoulders Being Around Machinery Driving Repetitive Leg Movements Exposure To Temperature / Humidity Changes Exposure To Dust, Fumes or Gases Normal Housework Caring For Personal Needs 6. Additional Comments

PHYSICIAN'S CERTIFICATION * A stamp or the signature of a person other than the examining physician is not acceptable.

I certify that I examined this person on _________________________________________________.
Date of examination (month, day, year)

Signature of examining physician * Printed or typed name of examining physician Indicate physician specialty Date signed (month, day, year)