Get Sample Forms - Missouri Department Of Health And Senior ...

Filling out the Sample Forms from the Missouri Department of Health and Senior Services can be a straightforward process. This guide provides comprehensive instructions to help you navigate each section of the form online, ensuring you can complete it accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the document and open it in your preferred online editor.
2. In Section I, provide the patient's identifying information, including the name, date of birth, last four digits of their Social Security Number, case name, case number, DSS employee name, telephone number, county, fax number, and the DSS office mailing address.
3. In Section II, have the physician complete their part. This includes the patient's prognosis regarding their disability, how it affects their ability to work, and any medical limitations if applicable. Ensure that all relevant boxes are checked and the required options are filled in.
4. In Part A of Section II, specify the nature of the disability and its duration. Check the appropriate status regarding the patient's ability to work and any pregnancy-related questions.
5. In Part B of Section II, indicate what activities the individual can perform on a workday by checking the corresponding boxes. Provide additional remarks or recommendations related to work restrictions.
6. In Part C of Section II, the physician should record the primary and secondary disabling diagnoses and provide any comments needed.
7. Section III requires the client, or the individual acting on their behalf, to sign the authorization allowing the physician or healthcare provider to complete and share the form with DSS. If applicable, include the names and dates of two witnesses.
8. Review all completed sections to ensure all information is accurate and all fields are filled appropriately. Once satisfied, save your changes, download the document, and print or share it as required.

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