13-12A Medical Report Form DHR-FIA 500 - dhr maryland 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the customer's name, date of birth, phone number, and address in the designated fields. Ensure accuracy as this information is crucial for identification.
3. In Section I, provide the health provider's information including their printed name, license number, NPI number (if applicable), and contact details. This section must be completed entirely.
4. For confirmation of pregnancy, if applicable, enter the expected delivery date. If pregnancy does not affect work capabilities, only complete the health provider section.
5. Move to Section II and assess employability. Select one of the options: Employable, Limited Employability, Temporary Incapacity, or Disabled. Fill in any required details based on your assessment.
6. In Section III, list all diagnoses along with their ICD-9 codes and describe how they impact the customer’s ability to work. Ensure that all information is accurate and comprehensive.
7. Finally, review all entries for completeness and accuracy before saving or sending the form back to the Department of Social Services as instructed.

Start using our platform today to fill out your forms online for free!