Disability Review Forms

Adult Disability Packet including:

  • Medicaid Buy-In Program for Working People with Disabilities (MBI-WPD)
  • Over 65 Pooled Trust

To be completed by the client or authorized representative:

  • Disability Questionnaire: DOH-5139 (English) (Español) (PDF)
  • Authorization for the Release of Information Pursuant to HIPAA - DOH-5173 (English) (Español) (PDF)

To be completed by the adult's doctor:

  • Medical Report for Determination of Disability: DOH-5143 (PDF)

For questions regarding disability documentation requirements email SDRU@health.ny.gov or call the State Disability Review Unit toll free number 1-866-330-0591 Monday through Friday 8am-5pm.


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