Doh 5139-2025

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4.8 out of 5

97 votes

The document is a Disability Questionnaire from the New York State Department of Health's State Disability Review Unit. It collects detailed information about an individual's medical conditions, treatment history, education, literacy, and work experience to assess eligibility for disability benefits. The questionnaire includes sections for personal identification, medical records, educational background, and employment history.

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Click ‘Get Form’ to open the doh 5139 in the editor.
Begin by entering your personal information in the designated fields, including your name, case number, and client ID number. Ensure accuracy as this information is crucial for processing.
In Part I, list all medical conditions affecting your daily life. Be detailed about how these conditions limit your activities.
For Part II, provide information about your medical records. Indicate if you have seen a primary care provider and list any other medical professionals consulted in the past year.
In Part III, answer questions regarding your education and literacy. This includes detailing any special education involvement and vocational training received.
Finally, in Part IV, document your work history over the past 15 years. Include job titles, duties performed, and reasons for leaving each position.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (97 Votes)
2017	4.2 Satisfied (78 Votes)

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