Try for free

NY OCFS-3122 Family-Type Home for Adults Evaluation

Family-Type Homes for Adults in New York provide 24-hour residential care for dependent adults but are not medical facilities, so anyone needing constant medical care should not be admitted or kept there. This two-page evaluation helps the resident, the operator and OCFS decide whether a person's needs can be met in such a home.

Who completes it

The resident's physician or other licensed medical practitioner completes all sections, and the form states that all spaces must be completed. The physician signs with the date of examination and the date the form was completed.

Submitting and payment

How to submit it
Give the completed evaluation to the home operator and the local department of social services that certifies the home; it becomes part of the resident's record.

Good to know

  • Section II covers primary and secondary diagnoses, recent surgery and acute illness, diet, allergies, activity restrictions, weight bearing, blood pressure, weight and required community medical services.
  • Section III lists all current prescription and over-the-counter medications with type, frequency, dosage and special instructions.
  • Section IV asks yes or no whether the person is ambulatory, can self-administer medications, is habituated to drugs or alcohol, is a danger to self or others, or is incontinent.
  • Section V asks whether the person needs nursing facility placement or a mental health evaluation, and where they were admitted from. Current edition: Rev. 08/2026.

Get the official form

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

Family-Type Home for Adults Medical Evaluation (Resident)

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.

See how Vero Documents works

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What is the key question on OCFS-3122?

Section V asks whether, in the practitioner's opinion, the individual's needs can be met by the support services available in a Family-Type Home for Adults. Follow-up questions ask whether the person requires nursing facility placement, and whether mental illness history means a mental health evaluation is needed.

Who reviews the OCFS-3122 evaluation?

The form says the information helps the individual and the home operator determine the level of care needed. It becomes part of the resident's record and is subject to review by the New York State Office of Children and Family Services, which supervises the Family-Type Home for Adults program.

Can I leave sections of OCFS-3122 blank?

No. The heading states that all spaces must be completed, and several fields offer 'None Known' or 'None' boxes, such as recent surgery and allergies to medications, food and other substances, so a negative answer can still be recorded.