Effective Date: 




Updated 5/2017



This form is completed by a physician trained in cardiac conditions who has evaluated the consumer. It is used by the counselor to help determine the consumer’s eligibility, additional diagnostics needed, and/or a plan for rehabilitation services. The form includes information about the consumer’s medical history, medications, functional ability, risk factors, treatment, and prognosis.


Copies and Distribution

No copies are required. The completed form is placed in the consumer’s paper file. If the consumer’s case is submitted to the state medical director for guidance or a decision about services, a copy of the form is included in the courtesy file.



The completed form is part of the consumer’s paper file and is retained until the end of the fiscal year the case file is closed, plus five years.

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