Arizona Department of Economic Security
Supplemental Nutrition Program
ABAWD Work Exemption Request
Patient/Participant:
Address:
The person listed above requests verification of their medical condition, participation in your program or their unfitness to work. Please complete the form. You or the person above should return the form to the Arizona Department of Economic Security (“ADES”).
Authorization for Release of Information:
I authorize the release of medical information, training, counseling or other personal information to ADES.
Signature Date
Verification:
Please answer 1 or more of the following questions. Please sign and date the form or have the form signed as requested
1. Is the person a participant in a vocational rehabilitation program, a mental health counseling program or a drug or alcohol treatment or counseling program?
___ Yes ___ No
Duration of Program ______
For the purposes of verifying a person’s participation in a rehab or counseling program, please have the director of the program or the person’s counselor sign this statement below.
2. Is the person receiving temporary or permanent disability benefits from a government or private source? ? ___ Yes ___ No
Name the source of benefits______
3. Does the person have a mental and/or physical illness or disability, temporary or permanent, that reduces the person’s ability to financially support him or herself? ___ Yes ___ No
List the illness or disability
4. Does the person have another condition or circumstance, temporary or permanent, that makes them physically or mentally unfit to work? (This does not require a disability.) ___ Yes ___ No
List the condition or circumstance:
If you answered yes to either question 4 or 5, list the expected duration of the illness, disability, condition or circumstance:
Less than 30 days ____ Other ______
More than 30 days ____
More than 6 months ____
More than 12 months/indefinite ____
I certify that the above information is true and correct.
Name (Please Print) Title/Profession Date
Signature Address Telephone
For questions 3 and 4, this form may be signed by one of the following:
· A physician, physician’s assistant, nurse, nurse practitioner, designated representative of the physician’s office, licensed or certified psychologist, social worker or any other medical professional.
· For the purposes of verifying a person’s participation in a rehab or counseling program, the director of the program or the person’s counselor may sign this statement.
· If the form is submitted unsigned, additional verification or signatures may be requested.
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