Form W-1210 "Snap Abawd Work Requirement Medical Report" - Connecticut

What Is Form W-1210?

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 July 1, 2016;
  • 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-1210 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form W-1210 "Snap Abawd Work Requirement Medical Report" - Connecticut

Download PDF

Fill PDF online

Rate (4.6 / 5) 30 votes
State of Connecticut
Department of Social Services
W-1210
(New 7/16)
SNAP ABAWD Work Requirement Medical Report
Patient/Participant Name
Client ID#
___________________________
____________________
Address
______________________________________________________________________
The patient listed above requests verification of their medical condition and/or
participation in your program. Please complete this form and sign it below. You or the
patient should mail the completed form to the following State of Connecticut Department
of Social Services (DSS) address:
DSS ConneCT Scanning Center
P.O. Box 1320
Manchester CT, 06045-1320
Please answer one or more of the following questions and then complete the signature
section below.
1) Is this patient pregnant?
yes
no
unknown.
If yes, what is the due date? ___/____/________
2) Is this patient addicted to drugs or alcohol?
yes
no
unknown
3) Is the patient a participant in a vocational rehabilitation program, a mental health
counseling program, or a drug or alcohol treatment or counseling program?
___yes ___no.
If yes, when did patient’s participation in the program begin?
_____________________
4) Does this patient have a temporary or permanent mental and/or physical illness or
disability that prevents him or her from working at least 20 hours per week on
average? __yes ___no
Pg. 1 of 4
State of Connecticut
Department of Social Services
W-1210
(New 7/16)
SNAP ABAWD Work Requirement Medical Report
Patient/Participant Name
Client ID#
___________________________
____________________
Address
______________________________________________________________________
The patient listed above requests verification of their medical condition and/or
participation in your program. Please complete this form and sign it below. You or the
patient should mail the completed form to the following State of Connecticut Department
of Social Services (DSS) address:
DSS ConneCT Scanning Center
P.O. Box 1320
Manchester CT, 06045-1320
Please answer one or more of the following questions and then complete the signature
section below.
1) Is this patient pregnant?
yes
no
unknown.
If yes, what is the due date? ___/____/________
2) Is this patient addicted to drugs or alcohol?
yes
no
unknown
3) Is the patient a participant in a vocational rehabilitation program, a mental health
counseling program, or a drug or alcohol treatment or counseling program?
___yes ___no.
If yes, when did patient’s participation in the program begin?
_____________________
4) Does this patient have a temporary or permanent mental and/or physical illness or
disability that prevents him or her from working at least 20 hours per week on
average? __yes ___no
Pg. 1 of 4
State of Connecticut
Department of Social Services
W-1210
(New 7/16)
SNAP ABAWD Work Requirement Medical Report
Signature Instructions for Medical Provider
Thank you for taking the time to complete this form on behalf of your patient. Please print (or stamp) your
name and sign below. We cannot accept the completed form without your signature. This form may be
signed by a licensed medical provider whose scope of practice, as defined by the Connecticut General
Statutes, permits him or her to diagnose and treat the conditions for which this form is being completed.
A licensed master social worker may complete this form relative to mental health disorders, but the co-
signature of a supervising physician, advanced practice registered nurse, psychologist, professional
counselor or licensed clinical social worker is required. A certified alcohol or drug counselor may sign to
verify that the patient is addicted to drugs or alcohol or enrolled in a drug or alcohol treatment or
counseling program.
Your Name
Title
Signature
(Please Print)
Provider Type (M.D., P.A., etc.)
License Number
Date
Telephone Number
Fax Number
For Additional Co-Signature (when required):
Name of Co-Signer
Title
Signature
(Please Print)
Co-Signer Provider Type (M.D., P.A., etc.)
License Number
Date
Telephone Number
Fax Number
Pg. 2 of 4
State of Connecticut
Department of Social Services
W-1210
(New 7/16)
SNAP ABAWD Work Requirement Medical Report
Return this form to:
The DSS ConneCT Scanning Center
PO Box 1320
Manchester CT 06045-1320
Make sure that your client number ID is on every document that you send in.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil
rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions
participating in or administering USDA programs are prohibited from discriminating based on
race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or
retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program
information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact
the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of
hearing or have speech disabilities may contact USDA through the Federal Relay Service at
(800) 877-8339. Additionally, program information may be made available in languages other
than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination
Complaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter
addressed to USDA and provide in the letter all of the information requested in the form. To
request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter
to USDA by:
(1)
mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2)
fax: (202) 690-7442; or
(3)
email: program.intake@usda.gov.
Pg. 3 of 4
State of Connecticut
Department of Social Services
W-1210
(New 7/16)
SNAP ABAWD Work Requirement Medical Report
You may also file discrimination complaints or request reasonable accommodations as
follows:
You have the right to make a discrimination complaint if you think we have taken action against
you because of your race, color, religion, sex, gender identity or expression, marital status, age,
national origin, ancestry, political beliefs, sexual orientation, intellectual disability, mental
disability, learning disability, or physical disability, including, but not limited to, blindness.
An individual with a disability may request and receive a reasonable accommodation or special
help from the Department of Social Services when it is necessary to allow the individual to have
an equal and meaningful opportunity to participate in programs administered by the Department.
If you asked for an accommodation or special help and we refused to provide it, you may make
a complaint to the Department’s Affirmative Action Division Director or any of the agencies listed
below:
Commissioner of Social Services
Attention: Affirmative Action Division Director/ADA Coordinator
55 Farmington Avenue
Hartford, CT 06106-5033
Telephone: 1-860-424-5040, toll free: 1-800-842-1508, TDD: 1-800-842-4524
Fax: 1-860-424-4948
Connecticut Commission on Human Rights and Opportunities
55 Farmington Avenue
Hartford, CT 06106
Telephone: 1-860-541-3400, toll free: 1-800-477-5737, TDD: 1-860-541-3459
Fax: 1-860-246-5265
Web: http://www.ct.gov/chro/site/default.asp
This institution is an equal opportunity provider.
Persons who are deaf or hard of hearing and have a TTD/TTY device can contact DSS at
1-800-842-4524. Persons, who are blind or visually impaired, can contact DSS at 1-860-424-5040.
Pg. 4 of 4
Page of 4