IFB AGENCY

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.