DOH-5151 01/24 Page 2 of 2 5. Please note if the child’s function/ behavior is age-appropriate; if not, note actual age level and describe basis for your observation.

DOH-5151_017551_Khachikian-Brown_lo03.pdf. Version. 17.0

Questionnaire of School Performance - DOH-5152. (PDF) For questions regarding disability documentation requirements email [email protected] or call the State Disability Review Unit toll free number 1-866-330-0591 Monday through Friday 8am-5pm.

Questionnaire of School Performance - DOH-5152. (PDF) For questions regarding disability documentation requirements call the State Disability Review Unit toll free number 1-866-330-0591 Monday through Friday 8am-5pm .

To meet the criteria of Medically Fragile for the HCBS Children’s Waiver, children/youth must have a documented disability on file, as demonstrated by one of the two options below. 1. Supplemental Security Income (SSI) Certification.

DOH 5224 - Medicaid Presumptive Eligibility for Pregnant Women Screening Checklist

Doc Types. Forms. Year

Report (OHIP-0005/ DOH-5151). When submitting a disability determination request, in addition to the Medical Report for Determination of Disability Form, the following forms should be submitted:

Appendix I - Additional Forms - DOH 5151 Childhood Medical Disability Report; DOH 5003 Medical Orders for Life Sustaining Treatment

Childhood Medical Disability Report - DOH-5151 (PDF) Questionnaire of School Performance - DOH-5152 (PDF) Description of Child's Activities - DOH-5153 (PDF) ... DOH-5288 Form. Notice of Decision For Discontinuance in the New York State 1915(c) Children's Waiver - …