Form Ldss-4526 - 2010, Medical Examination For Employability Assessment
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2LDSS-4526
(Rev. 06/10)
NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE
MEDICAL EXAMINATION FOR EMPLOYABILITY ASSESSMENT, DISABILITY
SCREENING, AND ALCOHOLISM/DRUG ADDICTION DETERMINATION
I.
CLIENT IDENTIFICATION
Print Client Name: _______________________________________________________________
Veteran:
Yes
No
Address: ____________________________________________________________________________________________________
Case #: ____________________
CIN: _____________________
DOB: _____________________
Reason(s) for referral: Client states that:___________________________________________________________________________
____________________________________________________________________________________________________________
II.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I authorize the examining physician to disclose to the Department of Social Services any information provided, any diagnoses made,
conditions revealed, and functional limitations identified, as a result of the examination given. I understand that this information will be
treated as confidential.
Client Signature x ______________________________________________________________________ Date: _________________
AUTORIZACION PARA DAR A CONOCER INFORMACION MEDICA
Yo autorizo al médico que me está examinando a dar a conocer al Departamento de Servicios Sociales cualquier información provista,
cualquier diagnosis, condiciones reveladas y limitaciones funcionales identificadas en base al examen realizado. Comprendo que esta
información será confidencial.
Firma del Cliente x _____________________________________________________________________ Fecha: ________________
III. MEDICAL INFORMATION
List All Medical Conditions. Include psychiatric and alcohol/drug addiction diagnosis using DSM-IV format. (List all medical diagnoses
and specify medical/clinical findings, including prognoses and how long each condition is expected to last.)
Medical Condition
Prognosis and Treatment Recommendations
Date of original
Expected Duration
including prescribed medications
diagnosis/diagnosis type
From Present
(Months)
Date:
1-3
4-6
Physical Health
7-11
12+
Mental Health
Permanent
Substance Use Disorder
Other
Date:
Physical Health
1-3
4-6
Mental Health
7-11
12+
Substance Use Disorder
Permanent
Other
Date:
Physical Health
1-3
4-6
Mental Health
7-11
12+
Substance Use Disorder
Permanent
Other
Date:
Physical Health
1-3
4-6
Mental Health
7-11
12+
Substance Use Disorder
Permanent
Other
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