Child Disability Packet for a Child or Young Adult Under the Age of 21
To be completed by the parent/guardian or authorized representative:
- Disability Questionnaire-DOH 5139 (PDF)
- Description of Child Activities-DOH 5153 (PDF)
- Authorization for the Release of Information Pursuant to HIPAA-DOH 5173 (PDF)
To be completed by the child's doctor:
To be completed by the child's teacher or administrator:
For questions regarding disability documentation requirements call the State Disability Review Unit toll free number 1-866-330-0591 Monday through Friday 8am-5pm .