New Jersey guardians of the person may have to file a periodic Report of Well-Being, and the CN 12042 is the clinician's part of it. A clinician meets it when a guardian brings the form after a recent medical evaluation of the incapacitated person. The certification states whether the person's condition has changed during the reporting period and whether the guardianship should continue unchanged or be modified.
The guardian fills in their own name, address and phone number and the incapacitated person's full legal name at the top. A medical professional such as an MD or DO who recently evaluated the person completes the rest and signs.
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Certification of Examining Professional
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Yes. The instructions say that if the examining professional wishes to use their own form, the guardian should make sure the statement addresses all of the information in the CN 12042: the examination date and place, any change in condition, and an opinion on continuing or modifying the guardianship.
The guardian completes only the header with their contact details and the incapacitated person's name, then gives the form to a medical professional, such as an MD or DO, who has performed a recent evaluation. The professional completes and signs the certification.