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Documentation is not required unless requested. Please select which type of documentation the client would provide if asked.
SUBJECT: Verification of information supplied by an Applicant for assistance in the home.
This person has applied for assistance with basic essential needs in their home to help continue living independently. Our funding through the City of Bellingham requires the Volunteer Chore Program to verify a disability for anyone under the age of 60 applying for services.
We ask for your cooperation in providing the following information and returning it to the person listed at the top of the page. Your prompt return of this information will help to ensure timely processing of the application for assistance. The applicant has consented to this release of information as shown below.
CLIENT RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances that would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of this consent.
Area to be completed by a Medical Professional
For each numbered item below select the option that accurately describes the person listed above.
1. Has a disability, as defined in 42 U.S.C. 423, which means;
- Inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months; or
- In the case of an individual who has attained the age of 55 and is blind, inability by reason of such blindness to engage in substantial gainful activity requiring skills or abilities comparable to those of any gainful activity in which he/she has previously engaged with some regularity and over a substantial period of time.
2. Has a physical, mental, or emotional impairment that:
- Is expected to be of long-continued and indefinite duration;
- Substantially impedes his or her ability to live independently; and
- Is of such a nature that the ability to live independently could be improved by assistance in their homes with essential basic services.
3. Has a developmental disability as defined in Section 102(7) of the Developmental
Disabilities Assistance and Bill of Rights Act 42 U.S.C. 6001 (8), i.e., a person with a severe chronic disability that:
- Is attributable to a mental or physical impairment or combination of mental and physical impairments;
- Is manifested before the person attains age 22;
- Is likely to continue indefinitely;
- Results in substantial functional limitation in three or more of the following areas of major life activity: (1) Self-care, (2) Receptive and expressive language, (3) Learning, (4) Mobility, (5) Self-direction, (6) Capacity for independent living, and (7) Economic self-sufficiency; and
- Reflects that person’s need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated.
4. Is experiencing a temporary physical or mental impairment that is affecting their ability to perform basic essential tasks that are critical to maintaining their independence. If so, what is the expected duration?
REQUIRED TO BE GIVEN TO EACH APPLICANT BEFORE SIGNING THE VERIFICATION FORM
The Volunteer Chore Program serves:
Seniors, 60 years of age or older (with proof of age-Photo ID or Birth Certificate)
Adults, 18 years of age or older with a functional disability. This disability may be considered “Ongoing” or “Temporary” by their medical provider and must interfere with their ability to do basic essential tasks in their home that is critical to retaining their independence.
TAcceptable Forms of Disability Verification/b>
- Disability Verification Form completed by a Medical Professional stating that the individual qualifies under the definition of disability; or
- The person receives Social Security Disability.
- For a temporary disability-Documentation of HEN (Housing and Essential Needs) eligibility through DSHS.