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) (PDF)
- Authorization for the Release of Information Pursuant to HIPAA - DOH-5173 (English) (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.
