Ldss 4526 Form – Fill Out and Use This PDF

LDSS-4526 (Rev. 06/10)

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

MEDICAL EXAMINATION FOR EMPLOYABILITY ASSESSMENT, DISABILITY

SCREENING, AND ALCOHOLISM/DRUG ADDICTION DETERMINATION

I.CLIENT IDENTIFICATION

Print Client Name: _______________________________________________________________ Veteran: ฀ Yes ฀ No

Address: ____________________________________________________________________________________________________

Case #: ____________________ CIN: _____________________DOB: _____________________

Reason(s) for referral: Client states that:___________________________________________________________________________

____________________________________________________________________________________________________________

II.AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I authorize the examining physician to disclose to the Department of Social Services any information provided, any diagnoses made, conditions revealed, and functional limitations identified, as a result of the examination given. I understand that this information will be treated as confidential.

Client Signature x ______________________________________________________________________ Date: _________________

AUTORIZACION PARA DAR A CONOCER INFORMACION MEDICA

Yo autorizo al médico que me está examinando a dar a conocer al Departamento de Servicios Sociales cualquier información provista, cualquier diagnosis, condiciones reveladas y limitaciones funcionales identificadas en base al examen realizado. Comprendo que esta información será confidencial.

Firma del Cliente x _____________________________________________________________________ Fecha: ________________

III.MEDICAL INFORMATION

List All Medical Conditions. Include psychiatric and alcohol/drug addiction diagnosis using DSM-IV format. (List all medical diagnoses and specify medical/clinical findings, including prognoses and how long each condition is expected to last.)

Medical Condition	Prognosis and Treatment Recommendations	Date of original	Expected Duration
	including prescribed medications	diagnosis/diagnosis type	From Present
			(Months)
		Date:
		Physical Health	1-3	4-6
		Mental Health	7-11	12+
		Substance Use Disorder	Permanent
		Other
		Date:
		Physical Health	1-3	4-6
		Mental Health	7-11	12+
		Substance Use Disorder	Permanent
		Other
		Date:
		Physical Health	1-3	4-6
		Mental Health	7-11	12+
		Substance Use Disorder	Permanent
		Other
		Date:
		Physical Health	1-3	4-6
		Mental Health	7-11	12+
		Substance Use Disorder	Permanent
		Other

LDSS-4526 (Rev. 6/10)								Page 2
IV. FUNCTIONAL LIMITATIONS (related to medical findings noted in Section III): (check column that applies)
	No. Evidence	Moderately				No. Evidence	Moderately
a.) Physical Functioning	of Limitations	Limited	Very Limited	b.) Mental Functioning		of Limitations	Limited	Very Limited
Walking				Understands and remembers instructions
Standing				Carries out instructions
Sitting				Maintains attention/concentration
Lifting, Carrying				Makes simple decisions
Pushing, Pulling, Bending				Interacts appropriately with others
				Maintains socially appropriate behavior
Seeing, Hearing, Speaking				without exhibiting behavior extremes
Using Hands				Maintains basic standards of	personal
				hygiene and grooming
Stairs or other climbing				Appears able to function in a work
				setting at a consistent pace
Other:				Other:

V.TREATMENT HISTORY (list for medical, psychiatric, alcoholism and drug treatment for the past Two Years)

		Type of Program/Provider	Length of Treatment
		i.e. Outpatient, Residential, Methadone
	Name of Program/Provider		(# of Months)
		(for addiction specify modality)
	___________________________________________	___________________________________________	___________________________________________
	___________________________________________	___________________________________________	___________________________________________
	___________________________________________	___________________________________________	___________________________________________
	___________________________________________	___________________________________________	___________________________________________

VI. CURRENT TREATMENT PROGRAM IDENTIFICATION (include medical, psychiatric, alcoholism and drug treatment as applicable.)

Program Name: ______________________________________________________________________________________________

Address of Client’s Treatment Site: _______________________________________________________________________________

Mailing Address (If different from above): __________________________________________________________________________

Treatment Program Contact: ______________________________________ Title: _________________________________________

Telephone #: (

) _____________________________________

Fax #: (

) _______________________________________

VII. LIMITATIONS ON WORK ACTIVITIES

a.Taking into consideration physical, mental and addiction limitation(s), describe any working conditions, environments, or work activities which are contraindicated: ____________________________________________________________________________

_________________________________________________________________________________________________________

b. Are these restrictions expected to last:

1-3 months

4-6 months

7-11 months

12+ months

permanent

c. Do you recommend referral to rehabilitation, including but not limited to, a mental health or alcohol/substance abuse, or a physical

rehabilitiation program? ฀Yes ฀ No

If yes, please specify: _________________________________________________

VIII. SCREENING FOR POSSIBLE SSI REFERRAL

Based on the evidence available to you, does this individual have severe impairment(s) which has lasted, or is expected to last at least 12 months? IF YES, please check _______ Explain briefly: _________________________________________________________

_________________________________________________________________________________________ If substance abuse is

also found, would such impairment be expected to continue if use of drugs and/or alcohol were to cease? ฀Yes ฀ No

IX. PHYSICIAN INFORMATION

Physician’s or Psychologist’s Name (please print): ___________________________________________________________________

Address: ____________________________________________________________________________________________________

Board eligible or certified specialty: _______________________________ Tele.#: ( ) ______________ Fax #: ( ) _____________

Is this client a patient of the examining physician? ฀ Yes ฀ No	If yes, for how long? ________
Date of Last Examination: __________________

Signature of physician or psychologist: x _______________________________________________________ Date: _____________

Please forward this completed form to Social Services Contact: ________________________________________________________

Telephone #: __________________ Address: _________________________________________________________________________