This is the OLD form used to prove disability for an applicant who has not already been found disabled by SSA. This includes people who are applying for Medicaid in the DAB (aka "SSI-related") category, for MBI-WPD, or to use an SNT to shield excess income or resources. It was revised in June 2012 - see new form posted at http://wnylc.com/health/entry/134/. The form revised in June 2012 shortens this form from the former 25-page form two a 2-page form, which will be less intimidating to doctors.

The old form consisted of numerous attachments that elicited information about the different body systems, such as a musculoskeletal or cardiac impairments. Those former attachments, while burdensome, were helpful to show the criteria for "meeting the listings"-- Step Three in the sequential evaluation process. While no longer required, you might find some of these attachments helpful as a guide for the physician to provide information about particular conditions.

Medicaid Alert issued by NYC Human Resources Administration instructing HRA staff how to process applications and renewals for consumers with pooled supplemental needs trusts. Dated April 26, 2006.

Publication from NYC Human Resources Administration regarding exclusion from income budgeting of excess income contributed to a pooled supplemental needs trust (SNT). Dated May 2004.

WNYLC no longer posts this document. Please visit http://nysarctrustservices.org/commtrust_trusttwo.php for the current version.

WNYLC no longer posts the Joinder Agreement. Visit http://nysarctrustservices.org/commtrust_trusttwo.php to find the current document.

Letter from Deputy Commissioner of DOH, Kathryn Kuhmerker, to Executive Deputy Director of HRA, Iris Jimenez-Hernandez, explaining the process for making disability determinations for Medicaid recipients with Pooled SNTs. Dated 2/2/05.

Dated 7/7/05

Addendum to Form LDSS-486T. This form is used by NYC HRA to establish that someone is disabled by reason of HIV/AIDS. Rev. 6/25/03.

Dated 4/26/06.