Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering your personal information in the designated fields. This includes your name, case number, client ID number, disability ID number, Medicaid application date, last four digits of your Social Security Number, and date of birth. Ensure all information is accurate.
3. Indicate whether you have applied to the Social Security Administration for disability benefits. If yes, provide the date of application and SSA decision date. Document the outcome and reasons for denial if applicable.
4. In Part I, provide detailed information about your medical conditions. List all diagnoses and explain how these conditions affect your daily functioning and ability to work. Include a list of medications you are currently taking.
5. In Part II, specify details regarding your medical records, including primary care providers and any other medical professionals you have seen in the last 12 months. Input names, addresses, phone numbers, and reason for visits.
6. Continue in Part II by listing any hospitals or health care facilities you have visited in the past year. Also report any agencies from which you have received assistance related to your impairments.
7. In Part III, share your educational background. Include the highest grade level completed, any special education involvement, and details about vocational training or additional education in the past year.
8. Complete the communication section by answering questions about your ability to read and write in English, and if any assistance was needed to fill out this application.
9. In Part IV, detail your employment history over the past 15 years, including job titles, responsibilities, and any relevant information regarding hours worked and reasons for leaving each job.
10. Once all sections are completed, review your form for accuracy. You can then save changes, download a copy of the completed form, print it, or share it as needed.

Complete your NY DOH-5139 form online today for a smoother application process.