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NYS Office of Temporary and Disability Assistance- TA and SNAP Employment Policy Manual

Appendix A- Page 7 Rev. 3/2022 Waiver of New York State Medical Review Procedure Instructions: Please read this form carefully. If you do not understand something, or if you have any questions, ask your worker. If you agree with the waiver requirements, please sign and date the form. You will be given a copy and your worker will keep a copy. The Medical Review Procedure

 The medical review procedure includes all of the things your worker will ask you to do to determine whether or not you have any health-related limitations that affect your ability to work or participate in employment and training programs. For example, you might have to undergo screening and evaluation or have your doctor examine you and fill out a form.

 Participating in the medical review procedure will help you and your worker decide which activities are best for you and if you will need extra help or services.

 If you are evaluated and found to have a disability or health-related limitation, the social services district will arrange for the help and services you need to participate in a work activity assignment made by the district.

 You decide whether or not to participate in the medical review procedure.

If You Decide Not To Participate in the Medical Review Procedure

 If you decide not to participate in the medical review procedure, you will have to participate in work activities and may not have your medical condition accommodated. You may not receive the help and services you need.

 You may change your mind at any time and ask for a medical review of your ability to work. If you cannot successfully participate in work activities without accommodations, and we believe it is because you might have a disability, you may be required to participate in the medical review procedure. Your Signature I have read this form and understand it. I do not want to participate in the medical review procedure. _______________________

____________________ Signature

Date _______________________ Worker Signature