Form ADM4316 "Statement of Psychiatric Disability" - Ohio

What Is Form ADM4316?

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

Form Details:

  • Released on May 1, 2018;
  • The latest edition provided by the Ohio Department of Administrative 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 ADM4316 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form ADM4316 "Statement of Psychiatric Disability" - Ohio

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DEPARTMENT OF ADMINISTRATIVE SERVICES
STATEMENT OF PSYCHIATRIC DISABILITY ADM4316
________________________________________________________________________ ____________________________________
Patient’s Name (Please Print)
Disability Claim Number
AUTHORIZATION: I hereby authorize any hospital or clinic, physician, nurse or practitioner, including my health
plan, the state’s mental health vendor, Optum, the Employee’s Assistance Program (EAP), the Bureau of Workers’
Compensation, the retirement system which I participate in or any other person, office or provider with knowledge of
my illness, injury or condition to provide the Ohio Department of Administrative Services (DAS) or its representative
and state agencies involved with my return to work or claim for disability benefits with complete information as to my
health and medical history, eligibility for Disability Retirement Benefits and any information required in connection
with this claim, hereby waiving any and all privileged character of such information. I also hereby authorize DAS or
its representative to release any such information it receives to my health plan, the state’s mental health vendor,
Optum, the Employee Assistance Program (EAP), the Bureau of Workers’ Compensation, the retirement system which
I participate in and state agencies involved with my return to work or claim for disability benefits. I understand my
health plan, the state’s mental health vendor, Optum, state agencies or other party acting as a representative for the
state may contact me regarding their services in assisting me to return to work. A photocopy of this authorization shall
be valid as the original. I understand that it is my responsibility under the Americans with Disabilities Act to contact
my employer if I wish to apply for reasonable accommodations under ADA or to obtain information about my rights
under ADA.
________________________________________________________________________ ____________________________________
(Patient Signature)
(Date)
This authorization will be valid for 18 months from date of signature. I understand, that I have the right to revoke this authorization at any
time prior to its expiration by providing written notice to the Disability Unit for the Ohio Department of Administrative Services, 30 East
Broad Street, 27th Floor, Columbus, Ohio 43215. However, I understand, that I may not revoke any action taken by DAS in reliance on this
authorization prior to the date DAS receives my written notice of revocation. Additionally, I understand that revoking this authorization may
impair further processing of my claim or result in my claim being discontinued.
NOTE TO TREATMENT PROVIDER: Please complete the following questions as thoroughly as possible. Failure to do so
may result in a denial of your patient’s benefits. Any cost for completion of this report is your patient’s responsibility.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,
except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information. “Genetic information” , as defined by GINA,
includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact
that an individual or an individual’s family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family
member receiving assistive reproductive services.
1.
Date rendered disabled. ____________________________________________________________________________________
2. DSM diagnostic code, with symptomology. ____________________________________________________________________
__________________________________________________________________________________________________________
_______________________________________________________________________________________________________
____________________________________________________________________________________________________
3. Please include interpretive results of MMPI or other psychological testing if done. ________________________________
__________________________________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________
4. Provide dates of treatment. _________________________________________________________________________________
__________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_______________________
5. List medications, changes in medications with dates changed, any side effects from medication and lab results.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
_____________________________________________________________________________________________________
_______________
ADM 4316 (rev 05/18)
(over)
DEPARTMENT OF ADMINISTRATIVE SERVICES
STATEMENT OF PSYCHIATRIC DISABILITY ADM4316
________________________________________________________________________ ____________________________________
Patient’s Name (Please Print)
Disability Claim Number
AUTHORIZATION: I hereby authorize any hospital or clinic, physician, nurse or practitioner, including my health
plan, the state’s mental health vendor, Optum, the Employee’s Assistance Program (EAP), the Bureau of Workers’
Compensation, the retirement system which I participate in or any other person, office or provider with knowledge of
my illness, injury or condition to provide the Ohio Department of Administrative Services (DAS) or its representative
and state agencies involved with my return to work or claim for disability benefits with complete information as to my
health and medical history, eligibility for Disability Retirement Benefits and any information required in connection
with this claim, hereby waiving any and all privileged character of such information. I also hereby authorize DAS or
its representative to release any such information it receives to my health plan, the state’s mental health vendor,
Optum, the Employee Assistance Program (EAP), the Bureau of Workers’ Compensation, the retirement system which
I participate in and state agencies involved with my return to work or claim for disability benefits. I understand my
health plan, the state’s mental health vendor, Optum, state agencies or other party acting as a representative for the
state may contact me regarding their services in assisting me to return to work. A photocopy of this authorization shall
be valid as the original. I understand that it is my responsibility under the Americans with Disabilities Act to contact
my employer if I wish to apply for reasonable accommodations under ADA or to obtain information about my rights
under ADA.
________________________________________________________________________ ____________________________________
(Patient Signature)
(Date)
This authorization will be valid for 18 months from date of signature. I understand, that I have the right to revoke this authorization at any
time prior to its expiration by providing written notice to the Disability Unit for the Ohio Department of Administrative Services, 30 East
Broad Street, 27th Floor, Columbus, Ohio 43215. However, I understand, that I may not revoke any action taken by DAS in reliance on this
authorization prior to the date DAS receives my written notice of revocation. Additionally, I understand that revoking this authorization may
impair further processing of my claim or result in my claim being discontinued.
NOTE TO TREATMENT PROVIDER: Please complete the following questions as thoroughly as possible. Failure to do so
may result in a denial of your patient’s benefits. Any cost for completion of this report is your patient’s responsibility.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,
except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic
information when responding to this request for medical information. “Genetic information” , as defined by GINA,
includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact
that an individual or an individual’s family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family
member receiving assistive reproductive services.
1.
Date rendered disabled. ____________________________________________________________________________________
2. DSM diagnostic code, with symptomology. ____________________________________________________________________
__________________________________________________________________________________________________________
_______________________________________________________________________________________________________
____________________________________________________________________________________________________
3. Please include interpretive results of MMPI or other psychological testing if done. ________________________________
__________________________________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________
4. Provide dates of treatment. _________________________________________________________________________________
__________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_______________________
5. List medications, changes in medications with dates changed, any side effects from medication and lab results.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
_____________________________________________________________________________________________________
_______________
ADM 4316 (rev 05/18)
(over)
6. Describe patient’s mood and affect. _________________________________________________________________________
__________________________________________________________________________________________________________
________________________________________________________________________________________________________
7 .
Comment on patient’s ability to carry out daily activities and follow instructions. _________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
8. ____
7 .
Describe patient’s behavior or any changes in behavior. _______________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________
8. Is there any evidence of a thought disorder? Please comment. ________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
_______________________
9. Comment on patient’s judgment and ability to concentrate. ___________________________________________________
________________________________________________________________________________________________________
______________________________________________________________________________________________________
_________________
10. Is there any impairment in memory? Please comment. _______________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________
11. Has patient been referred to another treatment source? If so, please provide name, address and copy of evaluation, if
available. ______________________________________________________________________________________________
________________________________________________________________________________________________
_______________________________________________________________________________________________________
__________________
12. Comment on how the combined symptoms and intensity interfere with job performance. ________________________
________________________________________________________________________________________________________
______________________________________________________________________________________________________
________________
13. Plan of treatment toward return to work with expected date of return. ________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
___________
14. Patient’s condition prevents them from working:
Temporarily
Permanently
For longer than 12 months
15. If disability is temporary, patient’s estimated date of release to return to work:
________ For regular occupation
Mo. ______ Day ______ Yr. ______
________ On a part-time basis
Mo. ______ Day ______ Yr.______
Part-time schedule: hours per day ______ days per week ______ # of weeks ______
________ For suitable work activities within the limitations listed above
Mo. ______ Day ______ Yr.______
Name (treatment provider) Please Print
Specialty
Federal ID #
Street Address, City, State, ZIP Code
Telephone (area code)
Fax (area code)
Email Address
Date form received
Date signed
Signature
ADM 4316 (rev 05/18)
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