DOH-5143 Medical Report for Determination of Disability-2026

1. Click ‘Get Form’ to open the DOH-5143 Medical Report in our editor.
2. Begin by filling out Section I – Identification. Enter the patient's name, date of birth, sex, case number, and address. Ensure all details are accurate for proper identification.
3. In the Medical Report section, provide a diagnosis and the date of the last exam. Include height and weight measurements as required.
4. For Exertional Functions, indicate what the individual is capable of doing by selecting appropriate options for lifting, carrying, standing, walking, sitting, pushing, and pulling.
5. Next, check any limitations under Non-Exertional Functions across sensory, postural, manipulative, environmental, and mental categories.
6. Finally, ensure that the provider signs the form and includes their printed name, date signed, specialty, office address, and phone number before submitting it along with medical records.

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