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West Virginia Income Maintenance Manual Chapter 13

West Virginia Income Maintenance Manual Page 16 Chapter 13 Determining Disability, Incapacity, and Blindness

• DFA-RT-5a: General Medical Examination Report, Children • DFA-RT-6: Medical Information/Diagnostic Request Letter Used to request a general physical examination, eye examination, or an outpatient psychological exam. It must be used with DFA-RT-5 and DFA-RT-5a when a general physical examination is needed. • DFA-RT-7: Specialist Consultation Used to obtain a consultation by a specialist at the request of the examining physician and/or the MRT. • DFA-RT-8: Request from Physician's Record Used to request a copy of medical information from a physician's records. This must be attached to the DFA-RT-8a in order for payment to occur. • DFA-RT-8a: Physician's Summary Used to obtain the physician's recommendation to the MRT. When this form is used it must have the DFA-RT-8 attached. • DFA-RT-9: Report from Hospital Records Used to request a copy of medical information from hospital records. Requests for special test results must be stated on the form. • DFA-RT-10: Inpatient Diagnostic Services Used to request hospitalization for specific procedures. Prior approval from the MRT is required. • DFA-RT-11: Physician's Hospital Services Used to request hospitalization for specific procedures. Prior approval from the MRT is required. • DFA-RT-15: Request from Psychiatrist’s Record Used to obtain medical information from a psychiatrist/psychologist. This must be included with the DFA-RT-15a and attached to the physician’s billing form in order for payment to occur. • DFA-RT-15a: Psychiatrist’s Summary NOTE: When the MRT requests an evaluation or consultation by any specialist including, but not limited to, a psychiatrist, cardiologist, orthopedist, etc., the DFA-RT-7 must be attached to the physician’s billing form in order for payment to occur.