<p>Suggestions for Using and Explaining Form PAFS-704</p><p>The PAFS-704 form and its Procedural Instructions are attached to this document. Below are some clarifying tips for its use, and tips for explaining this form to your clients.</p><p>The field entitled “Applicant Name” may be misleading. This should be the name of the household member for whom verification of disability is being requested. The client’s name will be entered under “Case Name”.</p><p>You would be wise to add your phone number along with your office address, in case there are questions from the doctor’s office...</p><p>Stress to the client that form PAFS-704 MUST be signed by the Doctor, NOT a nurse or an assistant. </p><p>Look over the options that the doctor may choose at the bottom on the front of the PAFS-704. </p><p> If the doctor chooses either of the first two options, the household member may be exempted from Work Registration.  If the doctor chooses one of the latter two, the person cannot be exempted.  Some doctors may misinterpret the word “extent” in the third option to refer to duration, whereas it is talking about degree of seriousness. </p><p>Make sure the client understands to explain to his/her physician that if it is unknown how long the person will be unable to work, we want the doctor to choose the first option, place a question mark in the (date) field, and then explain under “Remarks”. We can then exempt the person until the next Re-certification. </p><p>The back of the PAFS-704 can also be used to record an “office determination of disability”.  This is used for a client who has not yet applied or been approved for SSI or RSDI disability, but who would obviously not be able to obtain and maintain a job.  You must discuss it with your supervisor before you make such a determination. PAFS-704 COMMONWEALTH OF KENTUCKY FMTL-356 (R. 6/04) Cabinet for Health and Family Services Department for Community Based Services</p><p>STATEMENT OF DISABILITY OR INCAPACITY</p><p>Applicant Name ______</p><p>Case Name ______</p><p>Case Number ______</p><p>Date ______</p><p>[ ]</p><p>[ ]</p><p>Dear Physician:</p><p>The above-named individual has applied for or is receiving assistance from this Agency. In order to receive or continue to receive assistance, persons between the ages of 16 and 60 are to be employed, register for employment or be certified as disabled or incapacitated.</p><p>This individual states that he/she is unable to work and is under your care at this time. In order for our office to determine his/her eligibility for assistance, we request that you check the appropriate block below as applicable to your patient. If you feel that none of the statements are relevant to this person, a "Remarks" section is provided.</p><p>A signed CFS-1, Informed Consent and Release of Information and Records or CFS-1A Supplement, is attached. This individual is aware that he/she is responsible for any charges for services provided by you.</p><p>Worker's Signature ______</p><p>______(Street Address)</p><p>______(City) (State) (Zip Code) ______</p><p>PHYSICIAN STATEMENT In my opinion: [ ] This patient is temporarily disabled or incapacitated and can return to work on ______. (date) [ ] The patient is permanently and totally disabled and will never be gainfully employed. [ ] The extent of this patient's disability or incapacity cannot be determined at this time. Reason: ______[ ] This patient is not disabled or incapacitated and can be gainfully employed.</p><p>Remarks: ______</p><p>Signature ______, M.D.</p><p>Telephone Number ______Date ______PAFS-704, page 2 ______FOR AGENCY USE ONLY </p><p>Applicant Name ______Applicant Soc. Sec. Number ______</p><p>Case Name ______Case Number ______</p><p>The above-named individual is obviously disabled or incapacitated and cannot be registered for employment or referred for appraisal. This decision is based on the following:</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>The above-named individual can be expected to be able to return to work, register for employment or be referred for appraisal on ______. (date)</p><p>Worker's Signature ______Date ______COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services</p><p>FORMS MANUAL FMTL-356</p><p>PAFS-704 Statement of Disability or Incapacity (1) Procedural Instructions R. 6/1/04</p><p>Purpose</p><p>Form PAFS-704, Statement of Disability or Incapacity, is used to establish or disprove disability or incapacity of an individual claiming physical inability to work register for Family MA or food stamps. </p><p>This form is used for work registration exemption purposes ONLY and is not used to determine the deprivation factor of incapacity.</p><p>General Procedure</p><p>Form PAFS-704 is prepared in duplicate and upon completion by the physician the original is filed in the fold of the current Family MA or food stamp application or recertification, as appropriate, and the control copy destroyed.</p><p>*Form PAFS-704 is a two part form. If the individual claiming exemption from the work registration requirement is under a physician's care and is not obviously disabled or incapacitated, the identifying information is completed and the original of the form is forwarded to the physician with a self- addressed envelope for completion. Form CFS-1, Informed Consent and Release of Information and Records, and/or CFS-1A Supplement, completed according to instructions for the use of the form, MUST accompany the request.</p><p>If the individual claiming exemption from the work registration requirement is obviously disabled or incapacitated, the worker completes page 2 of the form, giving a detailed description of the individual's disability or incapacity.</p>