Form H3033, Report of Physical or Mental Examination

Effective Date: 7/2005

Availability

Word: H3033.doc

PDF: H3033.pdf

Instructions

Updated: 10/1997

PURPOSE

  • To provide a method for the examining physician to report the results of a medical examination of a TANF or Medical Assistance Only (MAO) client.
  • To provide the Disability Determination Section (DDS) with adequate medical information to determine a client's eligibility for TANF or Medical Assistance Only.
  • To serve as a record of the examining physician's opinions about therapeutic or rehabilitative measures which might improve the patient's condition. To record the examining physician's opinion about restrictions in the patient's activities indicated by the impairment and the estimated date of onset.
  • To record the examining physician's opinion about the client's ability to return to work, including when.

PROCEDURE

When to Prepare

The worker initiates Form H3033 when medical information is needed to determine eligibility for TANF or MAO based on incapacity.

Number of Copies

The worker prepares an original.

Transmittal

  1. By the Worker — Send the original to the physician. Attach to the Form H3033:
    • Form H4116 (State of Texas Purchase Voucher), the original and four copies.
    • Form H3035 (Medical Information Release/Disability Determination), the original.
    • A DHS postage paid envelope addressed to the worker originating the Form H3033.

    The Form H3033 and attachments may also be given to the client to take to the physician.

  2. By the Physician — The physician returns the original of Form H3033 and the original and three copies of Form H4116 to the worker.

    If the physician does not return the Form H3033 and Form H4116 within a 10-day period, the DHS worker must make tactful inquiry to obtain the information as soon as possible.

    Upon receipt of the Form H3033 from the physician, the worker should check that the physician's signature and dates are correct. Any omission should be corrected before routing the forms to the state office.

  3. By the Worker — Route the returned completed Form H3033 to the Disability Determination Section, state office. Make a copy for the case record. Attach to the Form H3033:
    • Form H4116 (State of Texas Purchase Voucher), the original and three copies.
    • Form H3035 (Medical Information Release/Disability Determination), the original.
    • Form H3034 (Disability Determination Socio-economic Report) the original.
  4. By the Disability Determination Section — Upon receipt of the above materials, DDS staff conducts a review and makes a decision. DDS staff sends the Form H3035 to the worker to document the decision.

Form Retention

Staff keeps Form H3033 for three years after the case is closed.

DETAILED INSTRUCTIONS

The worker completes the following items:

Please Return To: — Enter the name of the worker and the mailing address of the local office to which the physician should return the form in the envelope provided.

Identification

Patient Name — Enter the name of the person to be examined by the physician.

Date of Birth — Enter the person's date of birth, example: 07-01-40.

Address — Enter the person's mailing address.

Case Name — Enter the case name as shown on Form H1000-A and Form H1000-B.

Case No. — Enter the case number which corresponds to the case name.

Category — Enter the category(ies) for which disability determination is a factor.

App. No. — If a case number has not yet been assigned, enter the preprinted application number from the Form H1000-A being filed for this case.

SSAN — Enter the person's Social Security account number.

Worker — Enter the name of the worker authorizing the examination.

BJN — Enter the budgeted job number to which the case is assigned.

Mail Code — Enter the mail code of the local office to which correspondence about the case should be sent.

Medical Authorization Date — Enter the month, day, and year the worker authorized the medical examination.

The examining physician completes the remainder of Form H3033.

Top of Page