The New York
State Office of Temporary and Disability Assistance Form
This is one of the more complex forms that we are often asked
to fill out. It is an eight page double sided questionnaire.
Patients may bring this form in to clinic, or have it mailed directly to you.
The form request for complete medical documentation of impairment. The
questionnaire inquires about the patient's medical condition, and also requests
the submission of any medical records that document objective evidence of the
condition.
Here is a few helpful tips to filling out this form:
- Given the complexity of the form, unless you are not busy
in clinic, do not attempt to fill this form out while seeing patients.
Ask the patient to see if he/she is okay with you mailing back the form to NY
State (an address is always provided on the form), or if he/she would like to
come and pick up the form in one week.
- If you are mailing this out, make sure that the patient has
signed the consent form of medical information release (last page), prior to
filling out the form.
- "You may reply directly on the questionnaire, submit a copy
of your records, or provide a report on your letterhead, whichever
is most convenient. If you prefer to use our toll free dictation
service, please call any time, day or night: 1800-250-1996".
This is directly quoted from the instructions. This means you do not need to
go through all 8 pages to answer every question. You may simply provide a
summary of the patient's medical condition and any known impairment (to you).
- If you do not know, you DO NOT need to provide a medical
opinion about the patient's work limitations ( lift carry, duration
sitting, push/pull etc..) Just check the box on the bottom "I cannot
provide a medical opinion regarding this individual's ability to do
work-related activities.
- for more info read their website
www.OTDA.State.NY.US/DDD