Get Doh-5143. Medical Report For Determination Of Disability

Completing the DOH-5143 form is an essential step in the process of applying for disability benefits. This guide provides clear, step-by-step instructions to help users fill out the form accurately and effectively.

Follow the steps to fill out the DOH-5143 form online.

1. Press the ‘Get Form’ button to access the DOH-5143 form and open it in your preferred online editor.
2. Begin with Section I – Identification. Enter the patient’s name, date of birth, sex, case number, and contact information including the address, client ID number, disability ID number, and the last four digits of the Social Security Number.
3. In Section I – Medical Report, provide the requested information to the provider. This includes filling out the diagnosis(es), date of last exam, height, and weight.
4. Next, move to the Exertional Functions section. Indicate what the individual is capable of doing by selecting the appropriate responses for lifting, carrying, standing, walking, sitting, pushing, and pulling.
5. Then, complete the Non-Exertional Functions section by checking any limitations that exist in sensory, postural, manipulative, environmental, and mental functions.
6. Conclude this section by having the provider sign the form, print their name, indicate the date signed, and provide their specialty, office address, and office phone number.
7. Once all sections are completed and verified for accuracy, save the changes made to the form. You may then download, print, or share the completed form as necessary.

Start filling out the DOH-5143 form online today to complete your application for disability benefits.