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Printed Address SEE REVERSE SIDE FOR INSTRUCTIONS TR-264 07/2017 State Zip INSTRUCTIONS Individual needing assistance with cognition shall be a Kansas resident. Of Medicine MD Dr. of Osteopathy DO Dr. of Chiropractic DC Dr. of Podiatric DPM Licensed Optometrist OD licensed physician assistant PA advanced registered nurse practitioner ARNP registered under KSA 65-1131 Christian Science practitioner listed in The Christian Science Journal or a person clinically licensed by the Kansas behavioral...
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Read and understand the instructions provided with the certification form.
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Start by filling out the personal information section, including your full name, address, contact details, etc.
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Provide specific details about the cognitive disorder being certified, including the diagnosis, symptoms, and any relevant medical history.
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Who needs certification of cognitive disorder?
01
Individuals who have been diagnosed with a cognitive disorder and require official certification for various reasons.
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Healthcare professionals and organizations involved in the treatment and care of individuals with cognitive disorders.
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Educational institutions and employers who may need certification as part of their assessment or accommodation processes.
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Government agencies or legal entities that require certification for matters related to benefits, legal proceedings, or disability claims.
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What is certification of cognitive disorder?
Certification of cognitive disorder is a document that confirms a person has been diagnosed with a cognitive disorder, such as Alzheimer's disease or dementia.
Who is required to file certification of cognitive disorder?
Individuals who have been diagnosed with a cognitive disorder and wish to utilize accommodations or support services may be required to file certification of cognitive disorder.
How to fill out certification of cognitive disorder?
To fill out a certification of cognitive disorder, an individual must provide their personal information, details of their diagnosis, and any accommodations or support services needed.
What is the purpose of certification of cognitive disorder?
The purpose of certification of cognitive disorder is to document and verify an individual's cognitive impairment for the purpose of accessing accommodations and support services.
What information must be reported on certification of cognitive disorder?
Information reported on certification of cognitive disorder typically includes the individual's name, date of birth, diagnosis information, and details of recommended accommodations or support services.
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