How to Fill Out the DOH-3122: New York Assisted Living Medical Evaluation

To fill out the DOH-3122, you need a physician, physician assistant, or nurse practitioner to perform an in-person physical exam within 30 days of the admission date and complete all three pages of the form. The clinical sections are the provider’s job, not yours, but what you bring to the appointment largely determines whether the form gets completed accurately the first time. The current version is available directly from the New York State Department of Health at health.ny.gov/forms/doh-3122.pdf.¹

Who Signs the Form

Only three types of licensed professionals can complete and sign the DOH-3122: a physician, a physician assistant, or a nurse practitioner. The regulations require the form to be “written and signed” by one of these providers.² Family members can gather records and background information, but the clinical assessment belongs to the licensed provider alone.

Telehealth is not accepted. The New York State Department of Health has issued guidance confirming that video visits are not acceptable for the initial medical assessment tied to adult care facility admission.³ Vital signs, communicable disease screening, and functional observations all require the provider to be in the room.

The 30-Day Window

The provider must have physically examined the person within 30 days before the admission date. The form includes a certification statement where the provider confirms this.⁴ An evaluation done six weeks before move-in is stale and will have to be redone. Before you schedule the appointment, confirm the expected admission date with the facility and work backward from there.

What to Bring to the Appointment

The provider needs accurate source material to fill out the form properly. Showing up with the following records saves time and cuts down on incomplete entries:

Current medication list — a pharmacy printout is best. Include over-the-counter medications and supplements.
Medical history summary with primary and secondary diagnoses, past surgeries, and hospitalizations.
Allergy list covering drug, food, and environmental allergies.
Immunization records, especially influenza and pneumococcal vaccines, which the form asks about specifically.
TB test results if recent testing has been done. If not, the provider will need to order one.
Mental health records, including any psychiatric diagnoses, treatment history, or recent evaluations.
Functional observations from family or current caregivers about what the person can and cannot do independently — walking, eating, bathing, managing medications.

Pharmacy printouts matter more than most people realize. Medication errors on the form are the most common accuracy problem when people try to list prescriptions from memory.

What Each Page Covers

The form runs three pages. Knowing what sits on each one helps you anticipate what the provider will ask and spot gaps before you leave the office.

Page 1: Medical Review Findings

Page 1 opens with identifying information — name, date of birth, sex, home address, facility name, and date of exam. The provider then documents vital signs (blood pressure, pulse, respiration, temperature, height, weight), primary and secondary diagnoses, allergies, prescribed diet, influenza and pneumococcal vaccine status, TB screening results, a signed communicable disease statement, bladder and bowel continence status, and any ongoing laboratory services needed. The bottom of the page asks the reason for the evaluation: pre-admission, 12-month annual review, acute change in condition, or other.¹

Page 2: Functional Status and Mental Health

Page 2 shifts from clinical data to how the person functions day to day. The provider documents activity restrictions, dependence on medical equipment, and the level and frequency of assistance needed for ambulation, transfers, feeding, and managing medical equipment. The page also covers whether follow-up therapies, home care, or palliative care are needed; signs of dementia or other cognitive impairment and any testing done or recommended; mental health history, prior psychiatric hospitalizations, and whether a mental health evaluation is recommended.

The medication self-administration section gets especially close attention from facilities. Referencing 18 NYCRR 487.7(f)(2), the form lists seven tasks: reading a medication label, following dosage instructions, actually taking the medication correctly, measuring or preparing it, opening the container, storing it safely, and interpreting the label. If the person cannot handle even one of these, the provider checks a box indicating they are not capable of self-administering medications.¹ That finding drives the medication assistance the facility must arrange.

Page 3: Medication List and Certification

Page 3 opens with a complete medication list. For each prescription, the provider records name, dosage, type, frequency, route of administration, the diagnosis it treats, and the prescriber. This is where that pharmacy printout earns its keep.

The page then presents the statement of purpose covering all six facility types the form applies to — Adult Homes, Enriched Housing Programs, Residences for Adults, Assisted Living Residences, Enhanced Assisted Living Residences, and Special Needs Assisted Living Residences — making clear these are residential settings and not medical facilities. It closes with the physician certification, where the provider signs and dates a statement confirming they physically examined the person, that the person does not need hospital-level or nursing-home-level care, and that they are suitable for residential care in the relevant facility type.¹

Handle TB Testing Early

The TB section causes more delays than anything else on the form. The form accepts either a tuberculin skin test (TST) or a TB blood test such as QuantiFERON-TB Gold. If a TST is used, New York guidelines recommend two-step baseline testing, with the second test placed one to three weeks after the first. A second step is not needed if the person has a documented TST from the previous 12 months. A TB blood test does not require two-step testing.⁵

The provider also screens for symptoms of active TB: a persistent cough lasting more than three weeks, unexplained weight loss, night sweats, bloody sputum, or fever. If symptoms are present, active TB must be ruled out before admission unless the facility has an airborne infection isolation room, which adult care facilities generally do not.⁵ Starting the TB testing a few weeks before the scheduled DOH-3122 exam prevents a scramble, especially if two-step skin testing is involved.

Getting the Signed Form to the Facility

Once the provider signs the DOH-3122, it goes to the admissions office of the facility seeking the placement. The facility operator is responsible for receiving and reviewing the medical evaluation before making an admission decision.² Clinical staff may contact the signing provider to clarify medication details, functional limitations, or follow-up care recommendations.

Because the form contains detailed protected health information, it should be transmitted directly between the provider’s office and the facility rather than handed over as loose paper. Ask the provider’s office to send it to the facility’s admissions office by secure fax or electronic transfer, and request a copy for your own records. Some facilities will accept an approved substitute form, but confirm this with the specific facility before relying on one.⁴

Annual Re-Evaluations

The DOH-3122 is not a one-time document. The form itself includes a “12 month” checkbox, and the regulations require periodic reassessment. Under 18 NYCRR 488.4, medical assessments for enriched housing residents must happen whenever a change in condition warrants and no less than once every 12 months.⁴ For adult homes, 18 NYCRR 487.7 requires periodic evaluation of each resident’s needs and the facility’s ability to meet them at least once every 12 months.⁶

The 30-day rule applies to annual evaluations too: the provider must have physically examined the resident within 30 days before the date of the report.² An acute change — a fall, a new diagnosis, a significant decline in functioning — triggers a re-evaluation outside the normal annual cycle.

1
New York State Department of Health. Assisted Living Residence Medical Evaluation DOH-3122
2
Cornell Law School. New York Compilation of Codes, Rules and Regulations Title 18 Section 487.4 – Admission Standards
3
LeadingAge New York. DOH Issues Telehealth Guidance for ADHC, Home Health, Hospice and ACFs
4
Cornell Law School. New York Compilation of Codes, Rules and Regulations Title 18 Section 488.4 – Admission and Retention Standards
5
New York State Department of Health. Guidelines for Tuberculosis Control in Long Term Care Facilities
6
Cornell Law School. New York Compilation of Codes, Rules and Regulations Title 18 Section 487.7 – Resident Services