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Get Md Dhr/fia 500 2013
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How to fill out the MD DHR/FIA 500 online
The MD DHR/FIA 500 form is essential for assessing an individual's ability to participate in employment and training activities. This guide provides a clear, step-by-step approach to filling out the form online, ensuring users can complete it accurately and efficiently.
Follow the steps to complete the MD DHR/FIA 500 online
- Click the ‘Get Form’ button to access the MD DHR/FIA 500 form in your editor of choice.
- Fill in the department of social services name and address at the top of the form, along with the case identification information including customer ID number, case name, and district.
- Enter the return date for the completed form, followed by the LDSS fax number and the case manager's email address. This information is crucial for timely processing.
- Provide the customer's personal information including name, date of birth, phone number, and complete address (street, city, and zip code). This section ensures that the individual is properly identified.
- If the individual is pregnant, indicate the expected delivery date in the specified section. If pregnancy has no impact on work ability, only the health provider section is required.
- In Section I, provide detailed health provider information. This includes the printed name, license number, phone number, and address of the health provider. Ensure that the form is signed by a licensed physician or appropriate health professional.
- In Section II, evaluate the individual's employability status. Choose one of the options based on their capabilities: employable, limited employability, temporary incapacity, or disabled. Fill out any additional fields relevant to the selected option.
- In Section III, list all diagnoses along with their ICD-9 codes. Explain how these diagnoses impact the customer's ability to work, and confirm adherence to the prescribed treatment plan.
- Review all entered information for accuracy before finalizing. Once completed, you can save your changes, download the form, print, or share it as needed.
Complete your MD DHR/FIA 500 form online today for smooth processing!
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