Follow the steps to submit your form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin filling out the form by entering the date, case name, case number, district name, and address in the appropriate fields at the top of the form.
3. Provide the worker's name, file number, and phone number. These details are essential for processing your request.
4. Indicate your Medi-Cal status by checking the appropriate box: No Medi-Cal, Pending Medi-Cal, or Pending Plan Selection.
5. In Section 1: Behavioral Health, answer whether there is a psychiatric or substance abuse problem that may prevent work by checking either 'YES' or 'NO'.
6. In Section 2: Presumptive Disability, check 'YES' if any of the listed conditions are applicable. If you answer 'YES', proceed to sign at the bottom of the form and skip further sections.
7. If you answer 'NO' to Section 2, move on to Section 3: Functional Impairment. Indicate if a medical condition prevents full-time engagement in sedentary activities by checking the appropriate box.
8. Estimate the duration of the impairment from sedentary work by selecting the timeframe provided or specifying 'Other' if necessary.
9. If applicable, check any restrictions or limitations in the additional options provided.
10. After completing all relevant sections, print and sign your name as the medical provider, along with the date and your clinic's name, address, and phone number.
11. Finally, return the completed form to DPSS electronically if your clinic supports electronic submission, or fax it to the provided number.

Prepare to complete and submit your documents online with confidence.