Ldss 4526-2025

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The document LDSS-4526 is a medical examination form used by the New York State Office of Temporary and Disability Assistance for assessing employability, disability screening, and determining alcoholism or drug addiction. It includes sections for client identification, authorization for medical information release, detailed medical history, functional limitations, treatment history, current treatment program identification, work activity limitations, SSI referral screening, and physician information. The form aims to gather comprehensive medical data to evaluate the client's eligibility for assistance.

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Click ‘Get Form’ to open the ldss 4526 in the editor.
Begin with Section I, 'Client Identification.' Fill in your name, address, case number, and date of birth. Indicate if you are a veteran by selecting 'Yes' or 'No.'
In 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.
Proceed to Section III, 'Medical Information.' List all medical conditions, including psychiatric diagnoses. Provide prognosis and treatment recommendations for each condition.
In Section IV, 'Functional Limitations,' check the appropriate boxes that reflect your physical and mental functioning limitations based on the medical findings.
Complete Sections V through IX by detailing your treatment history, current treatment program identification, work activity limitations, SSI referral screening, and physician information.

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Versions	Form popularity	Fillable & printable
2010	4.8 Satisfied (101 Votes)
1998	4 Satisfied (33 Votes)

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