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LDSS-654 Rev. 2/05 SUBMITTING AGENCY TRANSMITTAL SHEET DISABILITY DETERMINATION REQUEST Batch cases by type. Use separate transmittal sheet for each type listed below. Check one box for each batch. TYPES MA ONLY PA ONLY AUDIT CASE MBI-WPD OVER 65 CHILD CASE DATE SENT NEW YORK STATE DEPARTMENT OF HEALTH Adult Cases Attach a DSS-1151 Disability Interview form a DSS-486T Medical Report for Determination of Disability and all available supporting medical evidence. Submit two 2 copies of each transmittal sheet. FOR AGENCY COMPLETION Name of Client Surname First Name KEY Case Number Disability Type MI Mental Impairment PI Physical Impairment MI/PI Combination of Both SIGNATURE For Agency REVIEW TEAM DETERMINATIONS Type Case Type N New CDR Continuing Disability Review TITLE Decision Effective Date Of I Group I DIS Disapproved NA No Action TELEPHONE NO. Child Cases Attach a DSS-1151 Disability Interview form Childhood Medical Report a Childhood Activity Report and the Questionnaire of School Performance. Continuing Disability Review CDR Cases Submit entire case record including all previous DSS-639 Disability Review Team Certificates. Child Cases Attach a DSS-1151 Disability Interview form Childhood Medical Report a Childhood Activity Report and the Questionnaire of School Performance. Continuing Disability Review CDR Cases Submit entire case record including all previous DSS-639 Disability Review Team Certificates.

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