Dss 3122 form-2026

The document DSS-3122 outlines the purpose and requirements for Adult Residential Care Programs, which provide 24-hour care for dependent adults who do not require constant medical supervision. It emphasizes that such facilities are not equipped for individuals needing extensive medical care. The document includes a medical evaluation form to assess the health and care needs of potential residents, detailing their medical history, medications, and ability to perform daily activities. This information is crucial for ensuring the well-being of residents and is subject to review by the New York State Department of Health.

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Click ‘Get Form’ to open the DSS-3122 in the editor.
Begin by filling in the resident's NAME and ADDRESS at the top of the form. Ensure accuracy as this information is crucial for identification.
In the MEDICAL HISTORY section, provide details about the PRIMARY DIAGNOSIS, RECENT SURGERY, and any CHRONIC ILLNESS. This helps assess the individual's care needs.
Complete SECTION II by listing all MEDICATIONS NEEDED, including TYPE, FREQUENCY, and DOSAGE. This ensures proper medication management.
In SECTION III, answer questions regarding the individual's capabilities and conditions. Use 'yes' or 'no' to indicate their ability for self-administration and mobility status.
Finally, in SECTION IV, provide a detailed opinion on whether the individual requires support from an adult residential care setting. Include any necessary justifications.
Ensure that a physician signs and dates the form at the bottom before submission.

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