The DOH-3122 form, titled the Assisted Living Residence Medical Evaluation, is a mandatory document issued by the New York State Department of Health. Assisted living facilities require this form before admitting any new resident to confirm that appropriate care can be provided.
Who needs to complete the 3122 form? Any individual applying for admission to a New York State licensed assisted living residence must have this evaluation completed by a licensed physician, physician assistant, or certified nurse practitioner. Family members and the resident cannot complete this form.
The form captures critical health data including vital signs, current medical diagnoses, prescribed medications with dosages, known allergies, dietary restrictions, immunization history, and tuberculosis screening results. It also evaluates the resident's ability to perform activities of daily living, including bathing, dressing, eating, mobility, and continence management. This assessment helps facility staff confirm whether the prospective resident's care needs fall within the services the assisted living facility can provide.
The completed 3122 form must be submitted to the assisted living facility before or at the time of admission. Facilities keep this documentation on file as part of the resident record. For related care planning documents, consider reviewing a New York medical power of attorney, a New York DNR form, or a New York living will to ensure complete care planning.
| Question | Answer |
|---|---|
| Form Name | 3122 Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | 3122 form, communicable continual doh, 3122 assisted living form, doh form 3122 |