Ldss 4526-2026

1. Click ‘Get Form’ to open the ldss 4526 in the editor.
2. Begin with Section I, CLIENT IDENTIFICATION. Fill in your name, veteran status, address, case number, CIN, date of birth, and reason for referral.
3. Move to Section II, AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. Sign and date to authorize the physician to share your medical information with the Department of Social Services.
4. In Section III, MEDICAL INFORMATION, list all medical conditions including psychiatric and substance use disorders. Provide prognosis and treatment recommendations for each condition.
5. Proceed to Section IV, FUNCTIONAL LIMITATIONS. Check the appropriate boxes that reflect your physical and mental functioning limitations based on the medical findings.
6. Complete Section V by detailing your TREATMENT HISTORY over the past two years including program names and types.
7. In Section VI, CURRENT TREATMENT PROGRAM IDENTIFICATION, provide details about your current treatment program including contact information.
8. Section VII requires you to describe any work activity limitations and expected duration of these restrictions.
9. For Section VIII, SCREENING FOR POSSIBLE SSI REFERRAL, indicate if severe impairments are present and provide explanations as needed.
10. Finally, complete Section IX with PHYSICIAN INFORMATION including their name, specialty, contact details, and signature.

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