MEDICAL REPORT
COUNTY USE ONLY
Case name Case number Worker name Worker number
SECTION I: PATIENT/CLIENT INFORMATION AND MEDICAL RELEASE
Name of patient/client (last, first, middle) / Nombre del paciente/cliente (apellido, primer nombre, segundo nombre)
Birth date / Fecha de nacimiento Social Security number / Número del Seguro Social Sex / Sexo Ages of children in home / Edades de los niños en el hogar
U Male/masculino
U Female/femenino
I authorize / Autorizo a ____________________________________ of / de _________________________________________________
Name of licensed physician or certified psychologist Name of clinic or medical group
Nombre del doctor con licencia o psicologo certificado Nombre de la clínica o grupo médico
to release my medical information on this form to the county welfare department. This authorization is valid for one year from the date signed
and I may ask for a copy of this authorization.
al departamento de bienestar público del condado para que proporcione la información médica que se solicita en este formulario. Esta
autorización es válida por un año a partir de la fecha de la firma y tengo derecho a solicitar una copia de esta autorización.
Patient/client signature / Firma del paciente/cliente Date/Fecha
³
SECTION II: PHYSICIAN OR LICENSED/CERTIFIED PSYCHOLOGIST INSTRUCTIONS AND CERTIFICATION
The county welfare department needs your information to determine if
the above-named person has a physical or mental incapacity that
prevents or substantially reduces the patient’s ability to engage in
full-time work, training, and/or provide necessary care for his/her
child(ren).
Please complete the rest of this form. Explain if you need additional lab
work or other exam(s) before you can determine the duration of
incapacity. If you need more space, use another sheet of paper and
attach it to this form.
1. Does the patient have a physical or mental incapacity that prevents or substantially reduces his/her ability to work full time at his/her
customary job?
U Yes If yes, expected duration:__________________
U Temporary, expect to release patient for full-time work on _________________________
(month, day, year)
U Permanent
U No
2. Does the patient have a physical or mental incapacity that prevents or substantially reduces his/her abililty to care for his/her children?
U Yes If yes, expected duration:__________________
U Temporary, expect to release patient for full-time work on _________________________
(month, day, year)
U Permanent
U No
3. List DIAGNOSIS and PROGNOSIS for this patient:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
4. Onset date: _______________________
(month, day, year)
O
I understand that the statements I have made on this form are subject to verification and investigation for welfare fraud.
O
I declare under penalty of perjury under the laws of the United States and the State of California that the information contained in this report
is true, correct, and complete.
Signature of physician, licensed certified psychologist, or person authorized to complete form Date
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Printed name and title/specialty Phone number
( )
Street address (mailing address, if different) City State ZIP code
MC 61 (05/07)
State of California—Health and Human Services Agency Department of Health Care Services
(County Stamp)
PLEASE GIVE THIS FORM TO THE PATIENT OR RETURN IT AND/OR OTHER
VERIFICATION WITHIN FIVE WORKING DAYS TO:
