MEDICAL CERTIFICATE – M01
1. Return to: 2. Claimant’s Name
Division of Temporary Disability Insurance BARSOUM, NABIL
PO Box 387 3. Date Disability Began 4. Soc Sec No
Trenton, NJ 08625-0387 10/21/2020 214-92-8564
5. Claimant’s Occupation 6. Form Identification Number 7. Form Date
22040750117 04/07/2022
INSTRUCTIONS: Go to: www.nj.gov/labor/MedicalApplicationTDI to complete your Medical Certificate via our
website. You must use the Form Identification Number listed above to submit the information.
22040750117
1. TREATMENT
Date of First Visit Date of Last Visit Date of Last Examination
_______________ ______________ _______________
Month Day Year Month Day Year Month Day Year
Frequency of Treatment Weekly Monthly Other, please specify _____________________________________
Dates of emergency room care or hospitalization: From _______________ To ______________________
Month Day Year Month Day Year
Date Disability Commenced (Enter the date the claimant was unable to perform his/her regular work.) _______________
Month Day Year
Was this patient referred to you? Yes No If yes, please supply the information below if available.
Name of referring doctor ____________________________________Referring doctor’s telephone ___________________________
Name and Address of any specialist treating patient: ________________________________________________________________
___________________________________________________________________________________________________________
Surgery Information
Type of Surgery _________________________________________ CPT4 Code__________ Date of Surgery _____________
Month Day Year
Anticipated Surgery Date _______________ Is surgery for cosmetic purposes only? Yes No
Month Day Year
2. DIAGNOSIS AND HISTORY
ICD Code(S): _________, __________, __________, ____________
Diagnosis: (nature and cause of this disability which prevents patient from working) _______________________________________
____________________________________________________________________________________________________________
Disability is: Due to an accident at work. Due to a condition which developed because of the nature of the work.
Not related to his/her job.
If pregnancy: Complete this question, skip Question # 3 and complete Questions #4 and #5.
Estimated Date of Delivery: ______________ Complications, if any:______________________________________
Month Day Year
Date Pregnancy Terminated: ___________________ Birth C-Section Miscarriage Abortion
Month Day Year
Objective Findings (i.e. x-rays, EKGs, MRIs, laboratory data and other clinical findings)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Claimant’s Name Soc Sec No
8564
MEDICAL CERTIFICATE – M01 continued
3. RESTRICTIONS AND LIMITATIONS
Physical Impairment – (if applicable) As defined in federal dictionary of occupations titles.
Indicate class of physical impairment.
Class 1 – No limitation of functional capacity; capable of heavy work. No restrictions (0 – 10%)
Class 2 – Medium manual activity (15 – 30%)
Class 3 – Slight limitation; capable of light work (35 – 55%)
Class 4 – Moderate limitation; capable of clerical/administrative (sedentary) activity (60 – 70%)
Class 5 – Severe limitation; incapable of minimum (sedentary) activity ( 75 – 100%)
Mental Impairment - (if applicable)
Indicate class of mental impairment.
Class 1 – No limitation Class 4 – Marked limitation
Class 2 – Slight limitation Class 5 – Severe limitation
Class 3 – Moderate limitation
What is this patient’s current DSM-IV-R diagnosis?
Axis I _________________________________ Axis IV _______________________________
Axis II _________________________________ Axis V _______________________________
Axis III _________________________________
Do you believe this patient is competent to endorse checks/direct the use of proceeds? Yes No
Cardiac – (if applicable)
Class 1 (no limitation) Class 2 (slight limitation) Class 3 (marked limitation) Class 4 (complete limitation)
4. PROGNOSIS
Please provide a specific date. Do not use “undetermined or indefinite”.
Estimated Recovery Date: _________________
Month Day Year
If now recovered, on what date was the patient first able to work? _________________
Month Day Year
5. CERTIFICATION AND SIGNATURE
I certify that the above statements, in my opinion, truly describe the patient’s disability and the estimated duration thereof:
_________________________________________________ ________________________________________________________
(Print Doctor’s Name and Medical Degree) (Original Signature of Doctor Required)
Doctor’s Address _____________________________________________________________________________________________
_____________________________________________________________________________________________
Telephone Number _________________________ FAX Number ______________________________
Certificate License No and State _________________ Specialty ____________________________________________
National Provider Identifier _________________ If resident, check Date Signed _______________________
