Form LDSS-486T Medical Report for Disability: Doctor Sign-Off, Submission, and Appeals

Form LDSS-486T, also labeled DOH 5143, is the one-page medical report a doctor completes when you apply for Disability Medicaid in New York State. Your local Department of Social Services sends it to each of your treating providers along with a request for your records. The completed form, your records, and a few supporting documents go to the State Disability Review Unit, which decides whether you meet the disability standard using the same criteria Social Security uses.¹ Expect the whole process to take up to 90 days.²

How You Get the Form

You don’t usually need to hunt it down. Once you file your Disability Medicaid application at your local Department of Social Services, the district mails or faxes the LDSS-486T directly to each of your treating providers with a cover letter asking for your records.³ If you want a blank copy, the official PDF is posted on the New York State Department of Health’s document site as “DOH 5143 (LDSS-486T) – Medical Report for Determination of Disability.”⁴ District offices also keep blank copies on hand.

What the Form Asks Your Doctor

The form has two parts. Section I is identification: your name, address, case number, Social Security number, sex, and date of birth. The local district fills this in before the form goes to your provider. Check it if you ever see it, because a wrong case or Social Security number can stall the file.

Section II is the medical report, and this is where the real content sits. It opens with your diagnosis or diagnoses, the date of your most recent exam, your height, and your weight.⁵ The rest is a functional capacity assessment, divided into two blocks of check-boxes.

The exertional block asks what you can still do physically:

Lifting, from under 10 pounds up to over 50 pounds
Carrying, in the same weight ranges
Standing, under 2 hours a day, 2 hours, or 6 hours
Walking, under 2 hours a day, 2 hours, or 6 hours
Sitting, under 6 hours a day or 6 hours
Pushing and pulling, broken out by right or left arm and leg

The non-exertional block covers five limitation categories: sensory (seeing, hearing, speaking), postural (stooping, bending, crouching, squatting, climbing), manipulative (upper-extremity use, right or left), environmental (dust, fumes, temperature extremes, heights, machinery, driving), and mental (understanding instructions, making work decisions, dealing with supervisors and coworkers, handling routine changes).⁵

The physician signs and dates the form, prints their name, and lists their specialty, office address, and phone number. One thing to notice when you talk to your doctor about this form: it is built around what you can still do, not just what you can’t. The form itself frames the goal as showing “the individual’s current condition, focusing on both remaining capabilities and limitations.”⁵ A doctor who checks limitation boxes without context gives the reviewer less to work with than one who describes what a workday actually looks like for you.

Who Can Sign It

The signature line reads “Signature of Physician,” and licensed physicians are the standard signers.⁵ The Department of Health has confirmed that nurse practitioners can also sign the DOH-5143, and the signing provider does not need to be enrolled as a Medicaid provider.⁶ Whoever signs should have examined you recently. The form has a “Date of last exam” field, and a report pulled from a months-old visit carries less weight than one from a current appointment. If your condition has shifted since you were last seen, book a visit before the form is completed.

What Goes With the Form

The LDSS-486T by itself isn’t the whole package. The GIS 12 MA/027 directive lays out what the local district has to gather before the case can go upstate for review:³

The LDSS-1151 Disability Questionnaire, which you (or your representative) fill out with your education, work history, job duties, physical demands of past jobs, and any prior SSI or SSDI applications
Medical records from the past 12 months from every treating provider, including progress notes and test results
Hospital, mental health facility, and nursing home records from any admissions during that period
The LDSS-654 Transmittal Sheet, which the district completes internally when sending the package to the State Disability Review Team

If a provider refuses to fill out the LDSS-486T but still sends records, the district can submit those records for review. When the evidence is too thin to decide the case, the district arranges a consultative examination at no cost to you.²

How the Form Gets Submitted

The instructions on the form tell the physician to return it to the agency named in Section I, which is the local Department of Social Services office that initiated the request.⁵ Most providers mail or fax it to the district along with the medical records. The NYC version of the form explicitly reminds providers to include “a copy of all medical records for the past 12 months” with the completed LDSS-486T.⁷

If you end up hand-delivering the form for your provider, ask the district office to date-stamp your copy. For mail, certified mail with a return receipt gives you proof it arrived. Keep a photocopy either way. If something goes missing from the district’s file, that copy is what rescues you.

What Happens Next and How Long It Takes

Once the district has the full package, it sends everything to the State Disability Review Unit. The reviewer applies the same disability test the Social Security Administration uses, looking at whether your impairment prevents substantial gainful activity.¹ If the file is incomplete, the district arranges a consultative examination by a state-designated provider, paid for by the district or the review unit.²

Disability Medicaid applications that need a medical evaluation can take up to 90 days.² Most delays come from slow provider returns or missing records. Call your providers to confirm they got the form, and check in with your caseworker before the package heads to the review unit.

If You’re Denied

A denial isn’t the end. Under New York Social Services Law Section 22, you have 60 days from the date on the denial notice to request a fair hearing.⁸ You can request one online at otda.ny.gov/hearings/request, by phone at (800) 342-3334, by fax at (518) 473-6735, by mail to NYS OTDA, Office of Administrative Hearings, P.O. Box 1930, Albany, NY 12201-1930, or in person at 5 Beaver Street in Manhattan.⁹

If you were already getting benefits and the notice is a reduction or termination, you can ask for “aid continuing” to keep them in place while the hearing is pending. That request has to be made within 10 days of the notice date, not 60, and you have to specifically ask for aid continuing. If you lose, you may have to pay back benefits you received during that stretch.

You can bring new medical evidence to the hearing that wasn’t in the original package. Cases denied for thin evidence often turn around here. If the LDSS-486T came back sparse or your 12 months of records had gaps, filling them in before the hearing is the move that matters.

What Records Can Cost You

Pulling together a year of records from multiple providers can get expensive. New York caps what physicians and institutions can charge at 75 cents per page plus postage for paper copies.¹⁰ If a provider quotes more than that, point them to the cap. Consultative exams and any testing the review unit orders are paid by the district or the state, not by you.²

1
Legal Information Institute. New York Codes, Rules and Regulations Title 18 360-5.3
2
New York State Department of Health. How to Apply for NY Medicaid
3
New York State Department of Health. GIS 12 MA/027 – Medical Evidence Gathering for Disability Determinations – Adult Cases
4
New York State Department of Health. DOH 5143 (LDSS-486T) – Medical Report for Determination of Disability
5
New York State Department of Health. LDSS-486T Medical Report for Determination of Disability
6
NYHealthAccess. Medicaid Disability Determinations – NYS Forms and Procedures
7
NYC Human Resources Administration. NYC Medicaid Alert – Medical Report for Determination of Disability
8
New York State Senate. New York Social Services Law Section 22 – Appeals and Fair Hearings; Judicial Review
9
NYC311. Public Benefit Fair Hearing
10
New York State Department of Health. Do I Have the Right to See My Medical Records?