SUBJECT:
INCOME MAINTENANCE FORMS
IM-60, MEDICAL REFERRAL AND AUTHORIZATION AND INSTRUCTIONS
IM-60A, MEDICAL REPORT INCLUDING PHYSICIAN’s CERTIFICATION/DISABILITY EVALUATION AND INSTRUCTIONS
IM-61, SOCIAL INFORMATION SUMMARY AND INSTRUCTIONS FORMS MANUAL REVISION #13
DISCUSSION:
The following Income Maintenance forms and instructions are revised and available online on the Intranet.
IM-60, Medical Referral and Authorization
IM-60A, Medical Report Including Physician’s Certification/Disability Evaluation
IM-61, Social Information Summary
The changes are as follows:
- All three forms updated the Division name to Family Support Division.
- All three forms are available on the Intranet and will not be printed.
Form IM-61, Social Information Summary
- All references to General Relief are removed;
- AFDC is changed to Temporary Assistance;
Work History Section
- A new column, “Gross Monthly Income Verified by Worker” is added; and
- the Wages/Hours column is changed to read “Client Statement of Gross Monthly Income”.
Additionally, two new questions are added asking the claimant if s/he works at a sheltered workshop and if s/he feels s/he is overpaid for his/her work. These questions are added to help clarify the earning capability of the claimant.
Expenses Section
This is a new section in which the claimant is asked if s/he has medical expenses that includes items and services needed in order to enable him/her to work. The claimant is asked to enter the type of expense, the expense to him/her, and the expense amount verified by the worker.
Some examples of expenses may be, but are not limited to, the following:
- Attendant care services
- Transportation costs
- Medical devices, such as wheelchairs and braces
- Work-related equipment and assistive devices, services, including helper animals
Medical Review Team Determination
In order to better determine medical eligibility for assistance, four questions are added to assist the Medical Review Team in determining whether or not the claimant meets the medical criteria for eligibility. This determination falls more in line with Social Security and how it determines eligibility based on disability. Other changes in this section are that:
- MRT has the option to make a recommendation in Item C. at the bottom of the second page; and
- MRT can also refer the individual to Vocational Rehabilitation.
Continue to use Form MO 650-2616, Authorization for Disclosure of Consumer Medical/Health Information (HIPAA Release Form) when completing form IM-60, Medical Referral and Authorization.
The PDF version of the IM-61 is currently online and available for use. Staff will be notified when the PDF version of the IM-60 and IM-60A become available for downloading. The word version will be available shortly thereafter and staff will be notified of the availability of the forms for online use.
NECESSARY ACTION:
- Review this memorandum with all appropriate staff.
- Remove the IM-60, IM-60A, and IM-61 forms and instructions with a revision date prior to 07/06 from the IM Forms Manual.