Department of Human Services

ABD Initial Application
RETRO PERIOD Reactivation
LONG TERM CARE Remand as a result of an Appeal
X02 Pre-release
PRINT ONLY Date Referred
LDSS:
Last First MI District:
Case Manager:
Telephone #:
Application Date Currently employed:
Yes See Attached completed SGA form
No
Date Required Information was received from the Customer/Representative
II. MEDICAL DETERMINATION ONSET DATE
No Medically Determinable Impairment ( Not Disabled )
Impairment(s) Not Severe ( Not Disabled )
Impairment(s) Severe but Not Expected to Last 12 Months ( Not Disabled )
Meets Listing (cite listing) ( Disabled )
Equals Listing (cite listing) ( Disabled )
Impairment(s) Severe but Doesn’t Meet or Equal Listing ( See Section III )
Medical Evidence Needed (Specify in comment section)
COMMENTS:
Signatures: MRT OPHTHALMOLOGIST DATE
MRT PHYSICIAN DATE
MRT PSYCHOLOGIST/PSYCHIATRIST DATE
III. MEDICAL VOCATIONAL DETERMINATION
Can Still do Past Relevant Work ( Not Disabled )
Can Adjust to do Other Work that Exists in Significant Numbers in the National Economy ( Not Disabled)
Cannot Make an Adjustment to do Other Work ( Disabled )
COMMENTS:
Signature: DISABILITY SPECIALIST: DATE:
DHR/FIA 707 (revised 9/25/13)Social Security #:
Client ID #:DISABILITY OR BLINDNESS DETERMINATION TRANSMITTAL
I. Client Name: Month 1 Month 2 Month 3

INSTRUCTIONS FOR FORM DHR/FIA 707
Transmittal for State Review Team
SECTION I
ABD/*Retro Period Request/X02: Place a check ( P) to identify the type of case
*Write the retro period month(s)
Date Referred: Indicate the date the referral is forwarded to the State Review Team.
Client’s Name: Print Only .
Social Security Number: Enter the client’s Social Security Number.
Client ID: Enter Customer’s Client ID.
LDSS/District: Enter the appropriate Local Department Name and District Office Number.
(Do Not Abbreviate )
Application Date: Date of Initial Application.
SECTION II
THIS SECTION IS FOR DISABILITY REVIEW TEAM USE ONLY
SECTION III
THIS SECTION IS FOR REVIEW TEAM USE ONLY
FORMS DISTRIBUTION: 1 copy – State Review Team (White)
1 copy – Local Department Case Record (Pink)
1 copy – LDSS Control Copy (Yellow)Date Required Information was received: Date all required information was received by the local department from the
Customer/Representative
Currently Employed: Check yes or no. If yes, attach the completed Substantial Gainful Activity (SGA) form. (Refer to the
Medical Assistance policy)
ONSET DATE: For the purpose of the Medical Assistance disability determination, this date represents the earliest date
the individual’s medical condition met the definition of disabled based on the medical evidence obtained. Case Manager/Telephone: Indicate the case manager’s first and last name assigned to the case and the corresponding
telephone number. ( Do Not Abbreviate )Initial Application/Reactivation/Remand as a result of an Appeal: Place a check ( P) in the appropriate box to identify the
type of information submitted.