Request for Medical Information NYC HRA Form
This form is required for requesting medical or clinical information for reasonable accommodation. It provides detailed instructions for both patients and providers. Completing this form will help facilitate your request with the Human Resources Administration.
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How do I fill this out?
To fill out the HRA-102d form, start by ensuring you have the necessary medical information from your provider. Next, complete pages 3 and 4 with accurate details about your condition. Finally, submit the completed form to HRA along with any required documentation.
How to fill out the Request for Medical Information NYC HRA Form?
1
Obtain the form from the Human Resources Administration.
2
Fill out the required sections with details about your medical condition.
3
Have your medical provider complete pages 3 and 4.
4
Sign the HIPAA Authorization on page 6 if needed.
5
Submit the form to HRA within thirty days.
Who needs the Request for Medical Information NYC HRA Form?
1
Individuals requesting reasonable accommodations due to medical conditions.
2
Healthcare providers completing documentation for patients.
3
Social workers assisting clients with accommodation requests.
4
Lawyers helping clients with disability-related claims.
5
Administrative staff processing medical information requests.
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What are the instructions for submitting this form?
To submit the completed HRA-102d form, you have several options: mail it to the Human Resources Administration's Office of Constituent Services at 150 Greenwich Street, 35th Floor, New York, NY 10007. Alternatively, you can fax the forms to 212-331-4685 or email them to ConstituentAffairs@dss.nyc.gov. Ensure to include your contact information for any necessary follow-up.
What are the important dates for this form in 2024 and 2025?
Important dates regarding the HRA-102d form submission will be provided as they are announced in 2024 and 2025. Keep a lookout for any updates related to deadlines or changes in submission procedures.
What is the purpose of this form?
The HRA-102d form is designed to collect necessary medical information to assess a person’s request for reasonable accommodation. This form aids in ensuring individuals with disabilities can access HRA services and programs effectively. By completing this form, applicants provide essential details enabling HRA to understand their needs and make informed decisions.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the individual requesting accommodation.
- 2. Social Security Number: Optional: Patient's social security number if known.
- 3. Provider Name: The name of the healthcare provider filling out the form.
- 4. Provider Address: The official address of the healthcare provider.
- 5. Date of Birth: Patient's date of birth.
- 6. Case Number: Optional: Patient's case number with HRA.
- 7. Provider Phone Number: Contact number for the healthcare provider.
What happens if I fail to submit this form?
Failure to submit the form may result in delays in processing your accommodation request. Without the necessary information, HRA cannot make informed decisions about your case. It is crucial to adhere to submission deadlines to avoid complications.
- Delayed Response: Your application may not be processed in a timely manner.
- Ineligibility for Accommodations: Without the submitted form, you may be deemed ineligible for needed accommodations.
- Increased Stress: Not completing the form could lead to uncertainty about your assistance.
How do I know when to use this form?
- 1. Requesting Accommodations: Use this form when you need adjustments due to medical conditions.
- 2. Providing Medical Information: It is necessary when healthcare providers need to document a patient's condition.
- 3. Appealing Decisions: This form may serve as part of the appeal process for accommodation requests.
Frequently Asked Questions
What is the purpose of the HRA-102d form?
The form is used to request medical information for reasonable accommodations from the Human Resources Administration.
How do I submit the completed form?
You can submit the form by mail, fax, or email as directed on the form.
Can my provider submit the form on my behalf?
Yes, your provider can submit the form if you sign the HIPAA Authorization.
What should I do if I don't receive a response?
If you do not receive a response, you may follow up with the HRA Constituent Services.
Is there a deadline for submission?
Yes, you need to submit the form within thirty days of your request.
Can I edit the PDF online?
Yes, PrintFriendly allows you to edit the PDF directly in your browser.
Do I need to sign the form?
Yes, a signature is required on the HIPAA Authorization if applicable.
What if I need assistance filling out the form?
You can contact HRA for assistance if you have difficulty completing the form.
Can I attach additional medical documentation?
Yes, you may attach additional documents to support your request.
How can I ensure my information is secure?
Make sure to submit your form directly to HRA through the provided methods.
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