Follow the steps to fill out the form effectively.

1. Press the ‘Get Form’ button to obtain the document and open it in your preferred editing tool.
2. Fill in the case name at the top of the form, ensuring that it is clearly stated for tracking purposes.
3. Enter the Commonwealth of Virginia and Department of Social Services details to contextualize the form.
4. Provide the case number in the designated field for reference by the relevant agency.
5. Complete the medical evaluation sections, starting with the patient's name and agency details, followed by the address and phone number.
6. Specify the patient’s birthdate in the format supplied on the form.
7. In the ability to participate section, check the appropriate box based on the patient’s current health status and state whether they require limitations or modifications.
8. Follow the prompts to indicate any anticipated duration of limitations or incapacity and whether the patient should apply for disability.
9. Record the total number of hours the patient can participate in employment and training activities by circling the appropriate value.
10. Describe any physical, psychiatric, or other limitations that could affect the patient's participation.
11. Provide the primary and any secondary diagnosis affecting the patient’s ability to engage in work activities.
12. Indicate compliance with prescribed treatments and medications as applicable.
13. Complete the referrals section if additional evaluations are necessary and provide details of the referring professional.
14. Ensure the form is signed by a qualified medical professional and include their identification details along with the date the form was completed.
15. After reviewing all inputted information for accuracy, you can save, download, print, or share the completed form as needed.

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