Doh 5139-2025

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78 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, and work experience to assess eligibility for disability benefits. The questionnaire includes sections on medical conditions, medical records, education and communication abilities, and past employment.

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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 a primary care provider and list any other medical professionals you've seen in the past year.
In Part III, answer questions regarding your education and ability to communicate in English. This section helps assess additional factors related to your disability claim.
Finally, complete Part IV by detailing 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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