DSHS Form 10-353 "Documentation Request for Medical Condition and Residual Functional Capacity" - Washington

What Is DSHS Form 10-353?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 10-353 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

ADVERTISEMENT
ADVERTISEMENT

Download DSHS Form 10-353 "Documentation Request for Medical Condition and Residual Functional Capacity" - Washington

Download PDF

Fill PDF online

Rate (4.5 / 5) 96 votes
Documentation Request for Medical Condition and
Residual Functional Capacity
Dear Health Care Provider:
For adult clients to get public assistance (TANF), they are required to work, actively look for work, or get training to work
for up to 40 hours per week. Some clients may not be able to meet this requirement because of health-related issues.
These clients may need temporarily deferral from a work activity, may be able to participate but for a limited number of
hours, or may need to avoid certain types of work activities.
(name of client) told us that they, or a family member they care for,
has a medical, mental or emotional condition which prevents or limits their ability to work, look for work or participate in
training to work.
Please complete the enclosed form to describe these medical limitations. If any condition duration is longer than
three months, please provide copies of objective medical evidence (chart notes, laboratory, imaging, and any
other diagnostic test) to verify condition. Please bill DSHS, not the client, for any costs related to providing this
information.
We will use this information to determine the level of required participation (up to 40 hours per week) in these types of
activities, and any limitations to consider in developing a customized activity plan based on the client’s medical needs.
Please provide the information by
(deadline date). If we do not receive any
medical information, we may require full-time participation, up to 40 hours a week, in work, job search or
training to work as described above. If the requirements are not met, cash benefits may be reduced or
terminated.
If you have any questions or need more time to send us the information, please call me at
(number of worker). You may send this completed document and any medical evidence to our statewide fax number at
1-888-338-7410 or mail it to DSHS, CSD – Customer Service Center, PO Box 11699, Tacoma WA 98411-6699.
Thank you,
Worker’s Name
DOCUMENTATION REQUEST FOR MEDICAL CONDITION AND RESIDUAL FUNCTIONAL CAPACITY
DSHS 10-353 (REV. 04/2020)
Documentation Request for Medical Condition and
Residual Functional Capacity
Dear Health Care Provider:
For adult clients to get public assistance (TANF), they are required to work, actively look for work, or get training to work
for up to 40 hours per week. Some clients may not be able to meet this requirement because of health-related issues.
These clients may need temporarily deferral from a work activity, may be able to participate but for a limited number of
hours, or may need to avoid certain types of work activities.
(name of client) told us that they, or a family member they care for,
has a medical, mental or emotional condition which prevents or limits their ability to work, look for work or participate in
training to work.
Please complete the enclosed form to describe these medical limitations. If any condition duration is longer than
three months, please provide copies of objective medical evidence (chart notes, laboratory, imaging, and any
other diagnostic test) to verify condition. Please bill DSHS, not the client, for any costs related to providing this
information.
We will use this information to determine the level of required participation (up to 40 hours per week) in these types of
activities, and any limitations to consider in developing a customized activity plan based on the client’s medical needs.
Please provide the information by
(deadline date). If we do not receive any
medical information, we may require full-time participation, up to 40 hours a week, in work, job search or
training to work as described above. If the requirements are not met, cash benefits may be reduced or
terminated.
If you have any questions or need more time to send us the information, please call me at
(number of worker). You may send this completed document and any medical evidence to our statewide fax number at
1-888-338-7410 or mail it to DSHS, CSD – Customer Service Center, PO Box 11699, Tacoma WA 98411-6699.
Thank you,
Worker’s Name
DOCUMENTATION REQUEST FOR MEDICAL CONDITION AND RESIDUAL FUNCTIONAL CAPACITY
DSHS 10-353 (REV. 04/2020)
WORKFIRST
Documentation Request for Medical Condition and
Residual Functional Capacity
CLIENT NAME
DATE OF BIRTH
CLIENT IDENTIFICATION NUMBER
NAME OF PATIENT EVALUATED IF DIFFERENT THAN THE CLIENT NAMED ABOVE
WORKFIRST STAFF NAME
TELEPHONE NUMBER
COMMUNITY SERVICES OFFICE (CSO) ADDRESS
To help the department determine the limitation(s) of the above-named individual, please provide the following
information:
1. Does this person have specific (please check the box)
physical,
mental,
emotional, or
developmental
issues that require special accommodations or considerations?
Yes
No
2. If yes, what is the type of condition(s) and the diagnosis?
Is this supported with objective medical evidence (testing, lab reports, etc.)?
Yes. If yes, please attach supporting evidence to this form.
No. If no, please address in Question 8.
3. Do the medical condition(s) listed above limit the person’s ability to work, look for work, or prepare for work?
Yes. If yes, check any applicable examples below.
No
Examples of limitations include the ability:
to lift heavy objects
concentrate for extended periods of time,
stand or sit for long periods of time
make repetitive motions,
follow instructions
interact with people,
bend over
tolerate exposure to chemicals, synthetic materials
reach above
gross or fine motor skills
memory retention
Please describe any other specific limitations not listed above:
If yes, this person should be limited to the following participation limits per week:
0 hrs (unable to participate)
1 – 10 hrs
11 – 20 hrs
21 – 30 hrs
31 – 40 hrs.
DOCUMENTATION REQUEST FOR MEDICAL CONDITION AND
RESIDUAL FUNCTIONAL CAPACITY
DSHS 10-353 (REV. 04/2020)
4. Does this person have any limitations with lifting and carrying?
Yes
No
If yes, this person has the following limitations:
Severely limited: Unable to lift at least 2 pounds or unable to stand or walk.
Sedentary work: Able to lift 10 pounds maximum and frequently* lift or carry such articles as files and small
tools. A sedentary job may require sitting, walking and standing for brief periods.
Light work: Able to lift 20 pounds maximum and frequently* lift or carry up to 10 pounds. Even though the
weight lifted may be negligible, light work may require walking or standing up to 6 out of 8 hours per day, or
involve sitting most of the time with occasional* pushing and pulling of arm or leg controls.
Medium work: Able to lift 50 pounds maximum and frequently* lift or carry up to 25 pounds.
Heavy work: Able to lift 100 pounds maximum and frequently* lift or carry up to 50 pounds.
* The person is able to perform the function for 2.5 to 6 hours in an 8-hour day and not necessary that performance be
continuous.
5. Does this person’s condition(s) impact their ability to access services (such as using the telephone, receiving
treatment, making and keeping appointments, using transportation services, or finding locations of services) or
advocating for themselves?
Yes
No
If yes, describe:
6. Is this person’s condition permanent and likely limit their ability to work, look for work, or train to work?
Yes
No; if the condition isn’t permanent, how long will this person’s condition likely limit their ability to work,
look for work, or train to work. Please use the space below to indicate the number of weeks or months:
Number of weeks, or
Number of months.
7. a. Is there a specific treatment plan you made to address this person’s health-related condition?
Yes
No
If yes, describe the treatment plan.
b. Who will be providing and monitoring the person’s ongoing treatment plan?
DOCUMENTATION REQUEST FOR MEDICAL CONDITION AND RESIDUAL FUNCTIONAL CAPACITY
DSHS 10-353 (REV. 04/2020)
8. Are there specific issues that need further evaluation or assessment?
Yes
No
If yes, please specify what type of assessment or evaluation might be needed to determine medical conditions and
plan to address. Please indicate if any further referrals to the specialist are required.
9. If the patient being evaluated is different than the client named because of the impact the patient’s condition has on
the client’s ability to participate, due to needing to care for the person in their home, please complete the following.
Given the child’s / adult relative’s condition, check the appropriate box:
The parent / caretaker can participate outside the home 0 – 10 hours per week.
The parent / caretaker can participate outside the home 11 - 20 hours per week.
The parent / caretaker can participate outside the home 21 - 30 hours per week.
The parent / caretaker can participate outside the home more than 30 hours per week.
Please contact me for further information.
How long do you expect the parent will need to provide this level of care:
Number of weeks
Number of months
Medical / Mental Health Care Provider / Other Professional
SIGNATURE
DATE
TELEPHONE NUMBER
PRINTED NAME AND TITLE
MAILING ADDRESS
CITY
STATE
ZIP CODE
WA
Authorization to Release Information
I authorize
to release to the Department of Social and Health
Services the information on this form and any medical record information that substantiates the illness/injury condition
that prevents me from working, solely to evaluate my capacity to participate in the WorkFirst Program. I understand that
this release specifically includes diagnostic testing or treatment information concerning mental health, alcohol or drug
abuse and the result of Sexually Transmitted Diseases (STD), including HIV/AIDS, when such information is part of the
record. (Revised Code of Washington (RCW) 78.24.105)
PATIENT’S SIGNATURE
DATE
DOCUMENTATION REQUEST FOR MEDICAL CONDITION AND RESIDUAL FUNCTIONAL CAPACITY
DSHS 10-353 (REV. 04/2020)
INSTRUCTIONS
DSHS WorkFirst Case Manager / Social Worker: The purpose of this form is to assist you in developing an Individual
Responsibility Plan when, as a result of a medical condition, or incapacity, there is an impact on the person’s ability to
work, look for work, attend training and/or access services. Use of this form is NOT mandatory if other
documentation exists. You may give this form to the applicant / recipient to take to the appropriate professional
service provider for completion or you may provide this directly to the provider by fax or mail. If you choose to mail this
form, obtain the client’s signature on the last page, and enclose pre-paid envelope.
DSHS Customer: The purpose of this form is to gather information from a medical provider that will assist your Case
Manager in reviewing your health issues and creating an Individual Responsibility Plan that best fits your specific needs
and limitations.
Physician / Health Care Provider: For adult clients to get public assistance (TANF), they are required to work, actively
look for work, or get training to work for up to 40 hours per week. Some clients may not be able to meet this requirement
because of health-related issues. These clients may need temporarily deferral from a work activity, may be able to
participate but for a limited number of hours, or may need to avoid certain types of work activities. Please complete this
form and give to client, send it to our statewide fax number 1-888-338-7410, or send to the WorkFirst Case Manager at
DSHS, CSD – Customer Service Center, PO Box 11699, Tacoma WA 98411-6699. Send us any notes, letters or other
documentation you already have in your records that address the person’s limitations.
DOCUMENTATION REQUEST FOR MEDICAL CONDITION AND RESIDUAL FUNCTIONAL CAPACITY
DSHS 10-353 (REV. 04/2020)
Page of 5