NY LDSS-1151 2012-2024 free printable template

LDSS-1151 Revised 6/2012 Attachment II AGENCY/ADDRESS DISABILITY QUESTIONNAIRE NEW YORK STATE Name Last First Middle DEPARTMENT OF HEALTH TO BE COMPLETED BY LOCAL AGENCY Case Number Client Identification Number Medicaid application date Yes No No Ineligible without disability review Social Security Number last 4 digits Family Health Plus eligible Date of Birth // Medicaid Waiver Telephone No. Waiver type / Yes Have you ever applied to the Social Security Administration SSA for disability...

How to fill out disability questionnaire form

How to fill out a disability questionnaire form:

1. Begin by carefully reading through the form to understand what information is being requested. Make sure to note any specific instructions or guidelines provided.
2. Start by filling in your personal information accurately, including your name, contact details, and any other required identification information.
3. Proceed to the section that asks about your medical history. Provide detailed and honest answers to each question regarding your disabilities or medical conditions. Be sure to include any relevant supporting documentation, such as medical reports or test results.
4. If the form includes a section for listing your daily activities and limitations, take your time to provide a thorough explanation of how your disabilities affect your ability to perform various tasks and activities. Give specific examples and include as much detail as possible.
5. Some disability questionnaire forms may ask about your employment history or educational background. Answer these questions truthfully and provide any additional information that may help in assessing your disability claim.
6. If there is a section for additional comments or explanations, take advantage of it to further elaborate on any important details that have not been covered in previous sections. This allows you to provide any relevant information that you feel is necessary for a complete understanding of your disability.

Who needs a disability questionnaire form:

1. Individuals who are seeking disability benefits or accommodations from government agencies such as the Social Security Administration or the Department of Veterans Affairs.
2. Employees who require workplace accommodations due to a disability. They may need to fill out a disability questionnaire form as part of the request process.
3. Students or applicants for educational programs who require disability accommodations. They may be asked to complete a disability questionnaire form to provide necessary information for determining appropriate support services.

Note: The specific need for a disability questionnaire form may vary depending on the country, organization, or situation in which it is being used.

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People Also Ask about disability questionnaire form

Can I fill out my own Dbq?

An advantage of a DBQ is that it can be filled out by your own personal physician if you'd rather not see a VA doctor for a C&P exam. Most often, DBQs are used to rate your condition in your initial claim or evaluate how much your service-related condition has deteriorated if you're filing for increased compensation.

What is the disability qualification questionnaire?

A Disability Benefits Questionnaire (VA DBQ) is a form that helps a VA healthcare provider or a private physician during an Compensation and Pension (C&P) exam to record information that is used in the claims process, to rate the conditions they are trying to obtain VA disability benefits for.

What is the disability questionnaire?

DBQs help collect necessary medical information to process your disability claims. You can use these forms to submit medical evidence from your health care providers. This information helps to support your claims for disability benefits.

What disabilities can the VA not prove?

No, there aren't any VA disability claims that cannot be proven. In fact, all VA claims must be proven on an “at least as likely as not” basis. If you have no evidence (no proof), your VA claim will get denied.

How do you answer a disability questionnaire?

How to Answer Disability Questionnaires Write clearly and legibly. Avoid erasures as much as possible. Do not leave any section of the form blank (unless otherwise specified). Give consistent answers. Answer the questions truthfully. Follow the instructions on the form.

Who can complete a Dbq?

Any doctor, including your primary care physician, can fill out a DBQ. If it is an area of specialty, such as cancer or mental health, the DBQ should be completed by a physician who is qualified in that area.

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What is the purpose of disability questionnaire form?

The purpose of a disability questionnaire form is to collect information from individuals with disabilities in order to assess their eligibility for certain services, accommodations, or benefits. The questionnaire helps to identify the individual’s needs and create a plan to best meet them.

What is disability questionnaire form?

A disability questionnaire form is a document used to collect detailed information and assess an individual's disability status. It is typically used by healthcare professionals, government agencies, or employers to evaluate the extent of an individual's impairment and determine their eligibility for various accommodations, benefits, or services. The form may include sections for personal information, medical history, functional limitations, and documentation of the disability. The responses provided in the form help decision-makers understand the impact of the disability on the individual's daily life activities and make informed decisions regarding support or assistance needed.

Who is required to file disability questionnaire form?

The specific requirements for filing a disability questionnaire form can vary depending on the jurisdiction and the purpose for which the form is being used. In general, individuals who are seeking disability benefits or accommodations may be required to fill out a disability questionnaire form. This can include: 1. Employees seeking disability accommodations in the workplace. 2. Individuals applying for disability benefits from government agencies, such as Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) in the United States. 3. Students seeking disability accommodations in educational institutions. 4. Individuals participating in medical research or clinical trials that require screening for specific disabilities or conditions. 5. Applicants for certain types of insurance policies that may require disclosure of pre-existing disabilities. 6. Individuals seeking accommodation or support services in public facilities, such as airports or public transportation systems. It is advisable to consult the specific requirements and regulations of the particular jurisdiction or organization in question to determine who is required to file a disability questionnaire form in a given context.

How to fill out disability questionnaire form?

Filling out a disability questionnaire form typically requires providing detailed information about your medical condition and any related limitations or disabilities. Below are general steps to help you fill out such a form: 1. Read the instructions: Start by carefully reading the instructions provided with the form. They will help you understand the purpose of the form and the information required. 2. Personal information: Begin by providing your personal details, such as your full name, date of birth, contact information, and Social Security number. Ensure that you have this information readily available before you start filling out the form. 3. Medical history: In this section, you will need to provide information about your medical condition(s). Include the names of the conditions, date of diagnosis, and the treating healthcare professionals. 4. Symptoms and limitations: Each form may ask for specific information about your symptoms and limitations. Describe your symptoms, when they occur, and how they impact your daily life and functioning. Be sure to include any physical, mental, or emotional limitations you experience as a result of your disability. 5. Medical treatments and medications: Provide details about any treatments you have undergone or are currently undergoing, such as surgeries, therapies, or medications. Include the names of medications, dosages, and frequency. 6. Medical records and supporting documents: Some forms may require you to attach copies of medical records, test results, or any supporting documentation related to your disability. Ensure that you attach all necessary documents as per the instructions. 7. Activities of daily living: The form may ask about your ability to perform daily activities. Describe any difficulties you face with tasks such as getting dressed, cooking, cleaning, and mobility. 8. Work history: If the form requires information about your employment history, provide details of your past jobs, including job titles, responsibilities, and dates of employment. Mention any accommodations made by your employers due to your disability. 9. Supporting statements: Many forms provide space for you to include additional information or statements from healthcare professionals, family members, or coworkers who can attest to your medical condition and its impact on your life. Consider including statements that support your disability claim. 10. Review and double-check: Before submitting the form, carefully review all the information you have provided to ensure accuracy and completeness. Make any necessary edits or additions. 11. Seek assistance if needed: If you find any aspect of the form confusing or need help completing it, consider seeking assistance from a legal professional, the relevant government agency, or a disability advocate. Remember to keep copies of the completed form for your records and submit it following the instructions provided by the organization or agency that issued the form.

What information must be reported on disability questionnaire form?

The information that must be reported on a disability questionnaire form may vary depending on the specific form and the purpose for which it is being used. However, some common information that is typically requested includes: 1. Personal details: Name, contact information, date of birth, social security number, and other identifying information. 2. Medical history: Details about the disability or medical condition, including its nature, diagnosis, duration, and any treatments or medications being received. 3. Functional limitations: Information on how the disability impacts the individual's ability to perform daily activities, work-related tasks, or other specific functions. 4. Medical provider information: Name, contact details, and any relevant medical records or reports from healthcare professionals involved in the treatment or diagnosis of the disability. 5. Work history: Employment information, including job titles, responsibilities, dates of employment, and any accommodations or changes made to assist with the disability. 6. Past disability benefits: Previous disability benefits or social security claims and their outcomes. 7. Additional documentation: Any supporting documents, such as medical records, test results, or other evidence that may help in assessing the disability.

What is the penalty for the late filing of disability questionnaire form?

The specific penalty for late filing of a disability questionnaire form can vary depending on the country and organization overseeing the process. In the United States, for example, there may not be a direct penalty for late filing of the form itself. However, the delay in submitting required forms or documents could potentially result in delays or denials in processing the disability claim or receiving benefits. It is important to adhere to the specified deadlines and guidelines provided by the relevant authorities to avoid complications or unfavorable outcomes.

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