Form Doh 3122 - Assisted Living Residence Medical Evaluation Form - New York Page 3
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3ASSISTED LIVING RESIDENCE
New York State Department of Health
MEDICAL EVALUATION
Division of Assisted Living
Patient/Resident Name: ________________________________________________
Da
te: ___________________
Resident will receive assistance with all medications unless physician indicates that resident is capable of self-
administration.
1. Does the patient/resident require assistance with medications (see criteria on page 2)? Yes
No
2. List all prescription, OTC medications, supplements and vitamins. Attach additional sheets if necessary or attach current discharge note, signed
by the physician, listing ALL medications.
Dosage
Type
Frequency
Route
Diagnosis/Indication
Prescriber (name of MD/NP)
Medication
STATEMENT OF PURPOSE
Adult Homes (AH), Enriched Housing Programs (EHP), Residences for Adults (RFA), Assisted Living Residences (ALR), Enhanced Assisted
Living Residences (EALR) and Special Needs Assisted Living Residences (SNALR):
•
provide 24-hour residential care for dependent adults
•
are not medical facilities
•
are not appropriate for persons in need of constant medical care and medical supervision and these persons should not be admitted or retained in
these settings because the facility lacks the staff and expertise to provide needed services.
•
Persons who, by reason of age and/or physical and/or mental limitations who are in need of assistance with activities of daily living, can be cared
for in adult residential care settings listed above, or if applicable, an EALR or SNALR.
PHYSICIAN CERTIFICATION
I certify that I have physically examined this patient and have accurately described the individual’s medical condition, medication regimen
and need for skilled and/or personal care services. Based on this examination and my knowledge of the patient, this individual (see
Statement of Purpose):
Yes
No Is mentally suited for care in an Adult Home/Enriched Housing Program/Assisted Living Residence/ Enhanced
Assisted Living Residence (EALR)/Special Needs Assisted Living Residence (SNALR).
Yes
No Is medically suited for care in an Adult Home or Enriched Housing Program/Assisted Living Residence / Enhanced
Assisted Living Residence (EALR)/Special Needs Assisted Living Residence (SNALR).
Yes
No Is not in need of continual acute or long term medical or nursing care, including 24-hour skilled nursing
care or supervision, which would require placement in a hospital or nursing home.
Name/Title of individual completing form:_____________________________________________ Date:____________
Physician Signature: ________________________________________________
Date _______________________
DOH 3122 (3/09) Rev. 5/12
Page 3 of 3
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