Form PA-4 "Physician Certification" - New Jersey

What Is Form PA-4?

This is a legal form that was released by the New Jersey Department of Human Services - a government authority operating within New Jersey. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on November 1, 2015;
  • The latest edition provided by the New Jersey Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PA-4 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Human Services.

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Download Form PA-4 "Physician Certification" - New Jersey

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New Jersey Department of Human Services
PHYSICIAN CERTIFICATION
Name (Last, First)
Sex
Medicaid No.
Male
Female
Home Street Address
Telephone Number
City, State, Zip Code
Veteran Status
Yes
No
Date of Birth
Social Security Number
Medicare Number
Primary Contact Name
Primary Contact Telephone No.
MEDICAL AND CARE NEEDS – TO BE COMPLETED BY PHYSICIAN
1. Primary Diagnosis:
Additional Diagnoses:
2. Medications:
3. Treatment/Therapies/Surgeries:
4. Does patient have any physical limitations?
Yes
No
If Yes, describe:
Please describe any related care needs:
5. Does patient have any emotional or behavioral problems?
Yes
No
If Yes, describe:
Is counseling or support required?
Yes
No
If Yes, explain:
6. Does patient require treatment for active tuberculosis?
Yes
No
7. Does patient require treatment for any mental illness?
Yes
No
8. Does patient have symptoms or a diagnosis of an intellectual or developmental disability or a related condition?
Yes
No
9. Is there a reasonable indication that patient might need hospital or nursing home care within 30 days without home and
community-based services?
Yes
No
I certify to the above-named individual’s diagnosis and related care needs.
Name of Physician (Print)
Signature
Date
Address
Telephone Number
PA-4
NOV 15
New Jersey Department of Human Services
PHYSICIAN CERTIFICATION
Name (Last, First)
Sex
Medicaid No.
Male
Female
Home Street Address
Telephone Number
City, State, Zip Code
Veteran Status
Yes
No
Date of Birth
Social Security Number
Medicare Number
Primary Contact Name
Primary Contact Telephone No.
MEDICAL AND CARE NEEDS – TO BE COMPLETED BY PHYSICIAN
1. Primary Diagnosis:
Additional Diagnoses:
2. Medications:
3. Treatment/Therapies/Surgeries:
4. Does patient have any physical limitations?
Yes
No
If Yes, describe:
Please describe any related care needs:
5. Does patient have any emotional or behavioral problems?
Yes
No
If Yes, describe:
Is counseling or support required?
Yes
No
If Yes, explain:
6. Does patient require treatment for active tuberculosis?
Yes
No
7. Does patient require treatment for any mental illness?
Yes
No
8. Does patient have symptoms or a diagnosis of an intellectual or developmental disability or a related condition?
Yes
No
9. Is there a reasonable indication that patient might need hospital or nursing home care within 30 days without home and
community-based services?
Yes
No
I certify to the above-named individual’s diagnosis and related care needs.
Name of Physician (Print)
Signature
Date
Address
Telephone Number
PA-4
NOV 15