Medical Review Team Packet
The Family Support Division needs the Medical Review Team (MRT) Packet in order to establish the disability.
Below find linked PDF versions of the individual documents and a brief explanation.
- IM-61B - Disability Questionnaire
- Fill in the client’s answers to all the questions, leave the pertinent information and observations of the Eligibility Specialist section blank.
- IM-61C – Work History
- The form asks for the past 10 years work history. Complete the form based on information readily available from the individual, do not delay submitting the form trying to get exact information. If the individual doesn’t remember specific information such as phone numbers, addresses, monthly income, etc. just put an approximation based on what is remembered.
- IM-61D – Doctor/Medical Facility List
- The form asks the individual to list all hospitals, medical facilities, and physicians from whom he or she has received medical care in the past 12 months. Mental health professionals, such as psychologists and licensed clinical social workers should also be included.
- MO 650-2616 – “Authorization for Disclosure of Consumer Medical/Health Information”
- to the Department of Social Services FSD Medical Review Team
- IM-60A – Medical Report form
signed by a psychiatrist or licensed clinical psychologist to certify that the client has a disability.
- At the top of the first page put the client’s name, date of birth and county.
- Leave blank the individual DCN, eligibility specialist, FAMIS user ID, load, date of app., date submitted to MRT as the FSD worker will fill those in.
- The most important parts of the form are Diagnosis section and the Determination of incapacity section.
- The form is optional, but the opinion the treating psychiatrist or licensed clinical psychologist is often a key piece of information in the disability determination.
- Record of Treatment
including an evaluation by a psychiatrist or licensed clinical psychologist and a Global Assessment of Functioning (GAF)
- RUSH cover sheet
When submitting the MRT packet and/or MO HealthNet application for the Elderly, Blind, and Persons with Disabilities, include the RUSH cover sheet as the first page of the material submitted.