Form W-303 "Client Supplement for Medical Information" - Connecticut

What Is Form W-303?

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

Form Details:

  • Released on February 1, 2008;
  • The latest edition provided by the Connecticut State Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form W-303 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Social Services.

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Download Form W-303 "Client Supplement for Medical Information" - Connecticut

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State of Connecticut
Department of Social Services
Client Supplement for Medical Information
W-303
(Rev. 2/08)
You asked for help from the Department of Social Services (DSS). You asked for this help because
you have health problems and cannot work. In order for the department to decide that we can give
you help because of your health problems, you must give us medical proof of your condition.
Your worker will give you the forms we need to decide if you can receive help. The department will
look at the information we get from your doctor(s) and from you to make that decision. If you need
help getting any forms or information sent to DSS from your doctors, talk to your worker. Your worker
will help you to get the information that you need and get the information returned to us.
Give form W-300, “Medical Report”, to your doctor to fill out. If you have more than one doctor,
ask your worker for more forms. Give one to each of your doctors. If you need help making an
appointment with your doctor because of your health problems, let your worker know. He or
she can help you make the appointment.
This form, W-303 “Client Supplement for Medical Information”, is for you to fill out. Use it to tell
us how your health problems keep you from working. This is your chance to tell us
anything you want us to know about your health problems and how they affect you. Be
sure to fill this form out completely. If you need help filling out this form, tell your worker.
He or she will help you fill it out or refer you to someone who can help you.
We may give you a form W-513, “Request for Medical Payment”. We will give this to you if you
do not already get medical help from DSS. The doctor needs the W-513 so that he or she can
bill the department for his or her services.
Sign a form W-303A, “Permission to Share Medical Information” for each of your doctors.
Once we receive the medical information, the department will review it and tell you our decision. If we
need more information, we will let you know.
If you do not agree with any decision we make, you can ask for a fair hearing.
If you disagree with a medical decision that we make for the SAGA program, you can also ask for
reconsideration. Your worker will be able to give you the W-1060 “Reconsideration Petition” form you
need.
This information is available in alternate formats. Phone (800) 842-1508 or TDD/TTY (800) 842-
4524.
State of Connecticut
Department of Social Services
Client Supplement for Medical Information
W-303
(Rev. 2/08)
You asked for help from the Department of Social Services (DSS). You asked for this help because
you have health problems and cannot work. In order for the department to decide that we can give
you help because of your health problems, you must give us medical proof of your condition.
Your worker will give you the forms we need to decide if you can receive help. The department will
look at the information we get from your doctor(s) and from you to make that decision. If you need
help getting any forms or information sent to DSS from your doctors, talk to your worker. Your worker
will help you to get the information that you need and get the information returned to us.
Give form W-300, “Medical Report”, to your doctor to fill out. If you have more than one doctor,
ask your worker for more forms. Give one to each of your doctors. If you need help making an
appointment with your doctor because of your health problems, let your worker know. He or
she can help you make the appointment.
This form, W-303 “Client Supplement for Medical Information”, is for you to fill out. Use it to tell
us how your health problems keep you from working. This is your chance to tell us
anything you want us to know about your health problems and how they affect you. Be
sure to fill this form out completely. If you need help filling out this form, tell your worker.
He or she will help you fill it out or refer you to someone who can help you.
We may give you a form W-513, “Request for Medical Payment”. We will give this to you if you
do not already get medical help from DSS. The doctor needs the W-513 so that he or she can
bill the department for his or her services.
Sign a form W-303A, “Permission to Share Medical Information” for each of your doctors.
Once we receive the medical information, the department will review it and tell you our decision. If we
need more information, we will let you know.
If you do not agree with any decision we make, you can ask for a fair hearing.
If you disagree with a medical decision that we make for the SAGA program, you can also ask for
reconsideration. Your worker will be able to give you the W-1060 “Reconsideration Petition” form you
need.
This information is available in alternate formats. Phone (800) 842-1508 or TDD/TTY (800) 842-
4524.
Client Supplement
Page 2 of 8
Part A. Tell us about yourself.
Name : _______________________________
DSS Client ID : _________________________
Address: ______________________________
SSN: _________________________________
_____________________________________
Date of Birth: __________________________
Phone: _______________________________
Sex:
Male
Female
1. Are you right-handed or left-handed?
Right
Left
2. Do you speak and understand English?
Yes
No
If no, what is your primary language? _______________
Do you need an interpreter?
Yes
No
3. Do you: (check one)
Live with friends or family
Live alone
Other ________
4. What is your living arrangement? (check one)
Home or apartment
Group home or halfway house
Nursing Home
Other ________________________
Homeless If homeless, do you live in an emergency shelter?
Yes
No
5. Are you able to drive a car?
Yes
No
6. How do you get from one place to another? (check all that apply)
Drive a car
Use Public Transportation
Walk
Dial-a-Ride
Ride with friends or relatives
Do you transfer from one bus/train/cab to another?
Yes
No
Do you need help getting in and out of a car, bus, van, etc.?
Yes
No
7. What is your height without shoes?
___________
___________
Feet
Inches
8. What is your weight without shoes?
___________
Pounds
9. Do you have problems seeing
Yes
No
If yes, do you wear contacts or glasses?
Yes
No
Do you have problems seeing even with glasses or contacts?
Yes
No
10. Do you have problems hearing?
Yes
No
If yes, do you wear a hearing aid?
Yes
No
Client Supplement
Name:____________________________
Page 3 of 8
Part B. Tell us about your health.
1. Tell us which doctors and clinics you are seeing for these health problems. Attach additional
sheets if necessary.
Please list your health
Name of doctor or
Address of doctor or
When did you see this
problems
clinic that is treating
clinic
doctor or clinic and when
(such as
(street, city and
arthritis, heart problem, HIV,
state)
you for this problem
is you next appointment?
back, depression, etc.)
Date first seen: __________
Date last seen: __________
Next appointment: _______
Date first seen: __________
Date last seen: __________
Next appointment: _______
Date first seen: __________
Date last seen: __________
Next appointment: _______
Date first seen: __________
Date last seen: __________
Next appointment: _______
2. In the last year, have you had an overnight stay in the hospital or have you been seen in a
hospital emergency room because of your health problems? Attach additional sheets if
necessary.
Name of Hospital
Address of Hospital
Reason for hospital
What date(s) were your
(city and state)
visit
visits?
From:
To:
From:
To:
From:
To:
From:
To:
3. Have your health problems become worse lately?
Yes
No If yes, please explain.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Client Supplement
Name:____________________________
Page 4 of 8
4. Are you taking any medications for your condition?
Yes
No
If yes, and you know the names of these medications, please list them here _________________
________________________________________________________________________________
________________________________________________________________________________
5. Tell us how these health problems keep you from working. _______________________________
________________________________________________________________________________
________________________________________________________________________________
6. Put a check in front of every statement that is true.
I feel sad a lot of the time.
I have much more energy than usual
I have problems sleeping.
I have problems concentrating or
(sleep too much or too little). I wake up at night.
thinking
I am not interested in activities I usually like.
I have panic attacks
I feel guilty or worthless
I hear voices when no one is there
My appetite has changed (I eat too much or too little)
I see things that others don’t see
I think people are trying to hurt me in some way
I have no energy
I feel nervous or anxious (worried) all the time
I think about hurting myself
I have problems staying awake during the day.
I think about hurting others
I have certain routines (for example, washing hands) that I must do over and over
7. Do you drink alcohol?
Yes
No
If yes, how much? _______________________________________________________________
_
How often? ____________________________________________________________________
8. Do you use drugs?
Yes
No
If yes, what kind? _______________________________________________________________
How often? ____________________________________________________________________
9. Have you received treatment for drugs or alcohol n the past two years?
Yes
No
If yes, please describe ___________________________________________________________
______________________________________________________________________________
Client Supplement
Name:____________________________
Page 5 of 8
Part C. Tell us about what you can do.
1. Tell us how much of the time you can do these activities? Check “Often”, “Sometimes”, or “Never”
for each activity.
Often
Sometimes
Never
Often
Sometimes
Never
Sitting
Lifting
Standing
Grasping
Walking
Pushing
Bending
Pulling
2. If you can you do any of these, put a check in the box that says, “Can Do”. If you need help to do
it, check the box that says, “Need Help”.
Can
Need
Can
Need
Do
Help
Do
Help
Shop for food
Exercise
Plan Meals
Household Chores
Cook
Count change
Read
Talk on the phone
Watch TV
Do arts & crafts
Play sports
Paint or draw
Listen to music
Knit or crochet
Ride a bicycle
Sew
Visit people
Walk
Use the computer
Jog (run)
Play video games
3. If you have problems doing an activity, check “Some Problems”. If you have a lot of problems
doing it check “Many Problems”.
Some
Many
Please tell us about the problems you are having in
Problems
Problems
each area
Paying attention
Learning new things
Remembering
Organizing
Listening
Reading
Going outside
Getting along with
others
Page of 8