Follow the steps to successfully complete the NY CAS-103 (E) form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the client’s name, date of birth, and Social Security number in the designated fields.
3. Provide the client's residential address accurately, ensuring all information is complete.
4. Indicate the client's gender in the appropriate field.
5. Enter the HRA address where all relevant medical reports and notes should be sent.
6. This section will require a physician, nurse practitioner, or physician’s assistant to fill out. They need to document the date of the client’s last medical visit.
7. List any current medical and mental health conditions affecting the client. Be as detailed as possible.
8. Record any current medications the client is taking in the provided space.
9. Answer the questions regarding the client's ability to travel to appointments, take public transportation, travel without a companion, attend appointments, and handle errands. Indicate ‘Yes’ or ‘No’ as applicable.
10. If any limitations are indicated with a ‘Yes’, provide detailed explanations in the designated section.
11. Specify whether the travel limitation is temporary, and if so, estimate the date when the client will be able to travel again.
12. Ensure the clinician’s name, title, and license number are printed clearly. The clinician must sign and date the form.
13. Finally, enter the clinician’s contact address and telephone number.
14. Review all entries for accuracy and completeness before saving changes, downloading, printing, or sharing the form.

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