Section 32-1-8.1 - MEDICAL INFORMATION TO ESTABLISH ELIGIBILITY AND FOR THE PROVISION OF SERVICESWhen an individual is in Application status, medical reports/examination, etc., are necessary to make a determination. When medical information is used as a basis to establish eligibility, the following guidelines shall be followed:
1. If a disability is reported and may be documented by medical Records but does not cause substantial functional limitations to activities of daily living or the condition is stable, this impairment does not have to be recorded on the Certificate of Eligibility. The Counselor's knowledge of this impairment and its stability, and the fact that it is not a factor to the rehabilitation process should be documented in Case notes or in the other section of the Certificate of Eligibility.2. Medical information does not have to be signed if the diagnostician, medical groups, or clinic is clearly identified in the information. DDS reports, hospital/VA records data on letterhead stationery, faxes to Counselors, copies of letter to other physicians, and letters to Counselors are acceptable3. Medical data not readily identifiable, handwritten notes, office/clinic notes, or pages from charts would all require a signature if the physician or office is not identified.4. Patients name must be on all medical data to ensure that there is no question concerning the identification of the consumer/client.5. Medical information, if used to help determine eligibility, must contain an actual diagnosis.6. Medical documentation must be in the file and dated on or before the date of the certificate of eligibility.7. Medical reports completed by a Family Nurse Practitioner (FNP) or Physicians Assistant must be co-signed by a physician to be acceptable.8. Medical reports completed/signed by the physician's office staff (i.e. secretary, nurse, etc.) are never acceptable. A disability will generally be considered stable if the answer is "no" to all the following questions:
1. Has the client's condition changed in the past year?2. Has the client been hospitalized during the past year as a result of his/her condition?3. Has the client's medication or therapy been changed in the past year?