New York's State Disability Review Unit sends this one-page report to treating providers when someone applies for Disability Medicaid without a Social Security disability determination. The provider lists diagnoses, then checks what the person can still do, such as lifting, standing, walking and sitting, plus sensory, postural, manipulative, environmental and mental limitations. The unit uses it to decide disability.
The treating physician or other medical provider completes the medical report, signs it and adds specialty and office details. The applicant completes separate disability questionnaires (DOH 5139 and DOH 5140).
Download the current version from the source each time; forms change without notice.
Disability Review Unit Medical Report for Determination of Disability
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The New York State Disability Review Unit uses it to decide Disability Medicaid for applicants who do not have a Social Security disability determination. The treating provider documents diagnoses, the date of last exam, and the person's exertional capacity and non-exertional limitations so the unit can reach an early decision.
Send a copy of all the patient's medical records for the past 12 months along with the completed and signed report. The form states this requirement in the note to the provider and again at the bottom of the page. Return everything to the State Disability Review Unit listed in Section I.
DOH-5143 is the current version of what was formerly numbered LDSS-486T. A short functional report replaced the older 25-page body-systems form, and the current revision is dated 8/18. The provider still focuses on remaining capabilities as well as limitations.