New York local social services districts, including HRA in New York City, use this two-page exam report when a Temporary Assistance or SNAP client claims a condition that limits work. The examining physician or psychologist lists every medical, psychiatric and substance use condition with its expected duration, then rates functional and work limitations. The district uses it for work requirement exemptions or limitations, rehabilitation and SSI referrals, and alcohol or drug addiction determinations.
The district completes Section I, client identification and the reason for referral, and the client signs the Section II release. The examining physician or psychologist, either the treating practitioner or one the district designates, completes Sections III through IX.
The district enters the client's name, veteran status, address, case number, CIN and date of birth, and the reason for referral as the client states it. Read the reason for referral before the exam; it tells you which condition the client says limits their work, though Section III asks you to list all conditions.
The client signs and dates a release authorizing the examining physician to disclose to the Department of Social Services any information provided, diagnoses made, conditions revealed and functional limitations identified during the exam, which will be treated as confidential. The release is printed in English and in Spanish (Autorización para dar a conocer información médica).
List all medical conditions, including psychiatric and alcohol or drug addiction diagnoses in DSM-IV format. For each, give medical or clinical findings, the prognosis and treatment recommendations including prescribed medications, the date of the original diagnosis, and the type: physical health, mental health, substance use disorder or other. Check how long each condition is expected to last from now: 1 to 3, 4 to 6, 7 to 11, 12 or more months, or permanent.
Rate each item as no evidence of limitations, moderately limited or very limited, based on the findings in Section III. Physical functioning covers walking, standing, sitting, lifting and carrying, pushing, pulling and bending, seeing, hearing and speaking, using hands and climbing stairs. Mental functioning covers instructions, attention and concentration, simple decisions, interacting with others, socially appropriate behavior, hygiene and grooming, and working at a consistent pace.
List medical, psychiatric, alcoholism and drug treatment for the past two years: program or provider name, type of program (outpatient, residential, methadone, with the modality for addiction treatment) and length of treatment in months. In Section VI, identify the program currently treating the client, with its address, mailing address, contact person and title, so the district can coordinate with it.
In part a, considering physical, mental and addiction limitations together, describe any working conditions, environments or activities that are contraindicated. In part b, check how long the restrictions are expected to last, from 1 to 3 months to permanent. In part c, say whether you recommend referral to rehabilitation, such as a mental health, alcohol or substance abuse, or physical rehabilitation program, and specify which.
Based on the evidence available to you, check whether the client has a severe impairment that has lasted or is expected to last at least 12 months, and explain briefly. If substance abuse is also present, answer whether the impairment would be expected to continue if drug or alcohol use stopped. Districts use this to decide whether to refer the client to apply for SSI.
Print your name, address, specialty and phone, say whether the client is your patient and for how long, and give the date of the last examination. Sign as physician or psychologist and date the form, then forward it to the Social Services Contact named at the bottom of the page.
Download the current version from the source each time; forms change without notice.
Medical Examination for Employability Assessment, Disability Screening, and Alcoholism/Drug Addiction Determination
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Sources for this guide
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The signature line is for the examining physician or psychologist. Section IX also asks for your board-eligible or certified specialty, whether the client is your patient and for how long, and the date of the last examination. The district may send the client to their own treating practitioner or to a health care practitioner it designates.
OTDA's posted version is in English, but the client release in Section II is printed in both English and Spanish, so a Spanish-speaking client can read and sign the authorization. The clinician sections, Sections III through IX, appear only in English.
The district uses your findings to decide whether the client is exempt from work requirements or can work with limitations, whether to refer the person to a rehabilitation program such as mental health or alcohol and substance abuse treatment, and whether to screen them for an SSI referral. Your duration estimates tell the district how long those decisions should last.