Medical examination for employability assessment, disability - labor state ny 2026

1. Click ‘Get Form’ to open the Medical examination for employability assessment in the editor.
2. Begin by filling out the Client Identification section. Enter your name, address, Social Security Number, and date of birth. Indicate if you are a veteran and whether you have an active SSI application pending.
3. In the Authorization for Release of Medical Information section, provide your signature and date to authorize the physician to share your medical information with the Department of Social Services.
4. Proceed to the Medical Information section. List all medical conditions, including any psychiatric diagnoses. Be thorough in detailing treatment recommendations and medications taken.
5. Complete the Functional Limitations section by checking the appropriate boxes that reflect your physical and mental functioning capabilities.
6. Fill out Treatment History by listing any relevant programs or providers you've engaged with over the past two years.
7. Identify your current treatment program details in Section VI, ensuring all contact information is accurate.
8. In Section VII, describe any work limitations based on your health status and indicate if these restrictions are expected to last longer than 90 days.
9. Finally, complete the Physician Information section with your physician's details and ensure they sign and date the form before submission.

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