Page 1171

West Virginia Income Maintenance Manual Chapter 13

West Virginia Income Maintenance Manual Page 18 Chapter 13 Determining Disability, Incapacity, and Blindness

• Case name; • Client’s name; • Date of the request; and, • Name of the provider to whom the request was sent. 13.7.1.B Obtaining Initial Medical Reports The following forms and instructions are used by the Worker to obtain initial medical reports. 13.7.1.B.1 DFA-PHI-1: Authorization for Information When the instructions in the following sections specify that form DFA-PHI-1 is included with a request for medical information, the date entered on the form must be no earlier than one month prior to the date it is mailed. The name of the provider must be placed on the form prior to the client's signature. 13.7.1.B.2 Physician’s or Psychiatrist’s/Psychologist’s Summaries Form DFA-RT-8 and DFA-RT-8a are sent to request information from physicians and forms DFA-RT-15 and DFA-RT-15a are sent to request information from psychiatrists/psychologists. If the physician or mental health professional fails to complete the form, a second one must be sent. The date the second one is sent must be noted on the DFA-RT-2. The Worker must indicate which sections of the form must be completed by the physician or psychiatrist/psychologist. NOTE: Medical reports must be requested within seven days after the date of application. In addition, follow-ups must be done every 30 days, when the medical reports are not received.

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Page 1171

Official source

West Virginia Income Maintenance Manual Chapter 13

West Virginia Income Maintenance Manual Page 18 Chapter 13 Determining Disability, Incapacity, and Blindness

• Case name; • Client’s name; • Date of the request; and, • Name of the provider to whom the request was sent. 13.7.1.B Obtaining Initial Medical Reports The following forms and instructions are used by the Worker to obtain initial medical reports. 13.7.1.B.1 DFA-PHI-1: Authorization for Information When the instructions in the following sections specify that form DFA-PHI-1 is included with a request for medical information, the date entered on the form must be no earlier than one month prior to the date it is mailed. The name of the provider must be placed on the form prior to the client's signature. 13.7.1.B.2 Physician’s or Psychiatrist’s/Psychologist’s Summaries Form DFA-RT-8 and DFA-RT-8a are sent to request information from physicians and forms DFA-RT-15 and DFA-RT-15a are sent to request information from psychiatrists/psychologists. If the physician or mental health professional fails to complete the form, a second one must be sent. The date the second one is sent must be noted on the DFA-RT-2. The Worker must indicate which sections of the form must be completed by the physician or psychiatrist/psychologist. NOTE: Medical reports must be requested within seven days after the date of application. In addition, follow-ups must be done every 30 days, when the medical reports are not received.