№ lp_2_3_04753
Form for healthcare providers to report the medical and functional limitations of clients affecting participation in work, job search, or training for public assistance.
Year: 2024
Region / City: Washington State, US
Type of Document: Medical and functional assessment request
Institution: Department of Social and Health Services (DSHS)
Target Audience: Adult clients applying for TANF and their healthcare providers
Form Number: DSHS 10-353
Period of Action: Ongoing assessment as of 2024
Deadline: Specified per individual case
Contact: WorkFirst staff member (phone number provided in form)
Instructions: Complete form with medical evidence if condition lasts longer than three months
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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