Get Ny Ldss-4526 2010-2025

The NY LDSS-4526 form is essential for assessing employability, disability screening, and determining issues related to alcoholism and drug addiction. This guide will help you navigate each section of the form to ensure that you fill it out accurately and efficiently.

Follow the steps to fill out the NY LDSS-4526 with ease.

1. Click the ‘Get Form’ button to access the form and open it in the editing interface.
2. Begin by filling out the client identification section. Enter the client’s name, veteran status, address, case number, client identification number (CIN), and date of birth. This information is crucial for accurately identifying the individual undergoing examination.
3. In the authorization for release of medical information section, ensure that the client signs and dates the form, granting permission for the physician to share medical details with the Department of Social Services.
4. Proceed to the medical information section. List all medical conditions, indicating whether these relate to physical health, mental health, or substance use disorders. Provide prognoses and treatment recommendations, specifying how long each condition is expected to last.
5. Next, complete the functional limitations section by checking the boxes that apply to the client. This includes assessing physical and mental functioning abilities.
6. In the treatment history section, document all medical, psychiatric, alcoholism, and drug treatment the client has received in the past two years, including the name of the program or provider and length of treatment.
7. Identify current treatment program information in the corresponding section. Provide details on the program name, address, and contact information.
8. Outline any limitations on work activities that the client experiences, noting expected duration and any recommended rehabilitation referrals.
9. For screening possible SSI referral, indicate if the individual has severe impairments that meet the necessary duration criteria and if these impairments would persist without substance use.
10. Finally, enter the physician's or psychologist's details, including their name, specialty, contact information, and the date of the last examination. Ensure the form is signed and dated.
11. After completing the form, save changes, and download or print the document as needed for your records or to submit it.

Encourage others to fill out the NY LDSS-4526 online to streamline their application process.