Get Dfa-dima-1 - West Virginia Department Of Health And Human ... - Dhhr Wv

Filling out the DFA-DIMA-1 form is an essential step for individuals seeking to have their disability or incapacity assessed by the West Virginia Department of Health and Human Resources. This guide will help you navigate the process smoothly and ensure that all necessary information is accurately provided.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the form and open it in your chosen editor.
2. Start by filling in the patient name and date of birth. Ensure the name matches official documents to avoid any delays.
3. Enter the Social Security Number as this is crucial for identifying the individual in the system.
4. Provide the name of the WV DHHR worker that is associated with your case, if known.
5. Read the confidentiality notice carefully. Ensure you understand the purpose of releasing your health information.
6. Sign the form to authorize the release of medical information, and include the date of your signature.
7. Your attending physician or their representative must complete the medical assessment sections, including diagnosis, prognosis, and expected duration of the disability.
8. Detail any employment limitations or difficulties that the individual may face due to their condition.
9. Indicate any accommodations that could allow the individual to participate in community services or educational activities.
10. Confirm if the individual can participate in educational activities with accommodations and provide explanations if necessary.
11. Provide information on whether the individual can engage in work or educational activities for at least five hours per week, and elaborate if they cannot.
12. Indicate if continuous assistance in the home is necessary for the individual due to their condition.
13. If applicable, state whether the individual is capable of caring for children under six years old.
14. Ensure the medical provider signs and dates the form. Their printed name, address, and phone number must also be included.
15. Review all entries for accuracy before moving to the final step.
16. Once completed, save your changes, and select the options to download, print, or share the form as needed.

Complete the DFA-DIMA-1 form online today to ensure a smooth assessment process.