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NY LDSS-3239 Medical Evaluation (Operator)

People who apply to operate an Adult Family-Type Home in New York, a family setting providing 24-hour care for one to four dependent adults, need a physician's evaluation of their own health. The one-page form records the operator's medical history and the physician's opinion on whether they are physically and mentally capable of caring for the residents.

Who completes it

The operator's physician completes the whole form: identifying details and examination date, Section I medical history and Section II evaluation, followed by the physician's name and address, signature and date.

Submitting and payment

How to submit it
Return the form to the local department of social services that certifies the home; the LDSS and OCFS use it to judge the operator's suitability.

Good to know

  • Section I has four boxes: recent surgery (type and date), recent acute illness (type and date), chronic illness or physical or mental limitations, and activity restrictions.
  • Section II asks yes or no whether the person is physically and mentally capable of providing adequate care and services to the dependent adults in the home, with a full description.
  • The statement of purpose notes that Adult Family Type Care is not a medical facility; residents need help with daily living, not constant medical care.
  • The current edition is LDSS-3239 (Rev. 12/2006); residents of the home are evaluated on the separate form OCFS-3122.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Evaluation (Operator)

Official pagePDF

Fill it with Vero

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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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What is LDSS-3239 used for?

It helps determine whether a person is suitable to be an Adult Family-Type Home operator. The local department of social services and OCFS, which supervise and certify Family Type Homes for Adults, use the physician's history and evaluation in that decision.

What does the physician decide on LDSS-3239?

Section II asks whether, in the physician's opinion, the individual is physically and mentally capable of providing the dependent adults living in the home with adequate care and services. The physician checks yes or no and is asked to describe the reasons fully.

How is LDSS-3239 different from OCFS-3122?

LDSS-3239 evaluates the operator who will run the home. OCFS-3122 evaluates each resident, covering diagnoses, medications, observations such as ambulation and incontinence, and whether the resident's needs can be met in a Family-Type Home for Adults.