The 16 Delaware forms that ask for a clinician's input, from workers' comp work-status reports and Paid Leave certifications to DMV, Medicaid and medical marijuana.
This page lists the 16 Delaware forms that ask for a clinician's input, grouped by program. On workers' comp claims the provider most responsible for treatment files the Physician's Report of Worker's Compensation Injury, Delaware's standard work-status form. Delaware Paid Leave uses the Certification of Serious Health Condition, completed online. DMV uses the MV474 for disability plates and placards and the MV-346 Physician's Findings Form for fitness to drive. Medicaid drug requests go on DMAP's Request for Medication Prior Authorization.
Send the workers' comp report to the worker, employer and insurer within 10 days of the first evaluation and with each progress or closing visit; office notes don't replace it. The Paid Leave certification asks three questions, no diagnosis, and is due within 30 days of the claim. DMV needs the original MV474, not a fax or scan. Since August 2024, reporting medical conditions to DMV is no longer mandatory, though practitioners are encouraged to report. All forms here are in English.
Required report of the employee's condition and limitations (diagnosis, safe work capacities, modified/full-duty release) from the provider most responsible for treatment under 19 Del. C. 2322E.
Prescriber's justification and certification that lets a pharmacist dispense a non-preferred or brand-name drug outside the Delaware workers' compensation preferred drug list.
Health care provider confirms whether the illness or injury meets the FMLA definition of a serious health condition, how many weeks of leave are needed, and whether reduced-schedule or intermittent leave applies, for Delaware Paid Leave medical or family caregiver leave.
Health care provider certification for an employer's Unum-insured private plan under Delaware Paid Family and Medical Leave.
Reports visual acuity, eye disease, field defects and recommended license restrictions for a driver license applicant.
Licensed practitioner's findings on neuropsychological, neurological, orthopedic, cardiopulmonary, diabetic, vision/hearing, substance-use and medication issues, with a recommendation on whether the customer should be allowed to drive.
Requests that DMV re-examine a person's ability to safely drive under 21 Del. C. 2714(c), with the reason in detail.
MV474Applies for a long-term disability license plate/parking placard or a temporary (180-day) placard, with physician certification under 21 Del. C. 2134/2135.
General DMAP pharmacy prior authorization for non-preferred PDL drugs, quantity limit overrides and medical necessity requests.
Physician's medical report used to determine whether a long-term care Medicaid applicant meets nursing home level of care (facility or community).
Practitioner's statement of diagnosis, prognosis and medical necessity supporting DMAP coverage of supplies and durable medical equipment.
Fee-for-service DMAP prior authorization request for DME, home health care, surgery/diagnostic testing, therapies and other services.
Delaware-licensed practitioner identifies the medical condition(s) for which the adult patient should receive a standard or terminal-illness medical marijuana card; patients 65+ may self-certify on the same page.
Pediatric specialist certifies the medical condition(s) qualifying a patient aged 17 or younger for a pediatric medical marijuana registry card.
Online report of suspected child abuse or neglect to the Division of Family Services Child Abuse & Neglect Report Line.
Physician, PA or advanced practice nurse certifies under oath that terminating electric or gas service would adversely affect a Delaware patient's health or recovery, giving Medical Alert status for 120 days.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Within 10 days of the first evaluation, and again with each progress or closing visit. The health care provider most responsible for treatment sends copies to the injured worker, the employer and the insurer, as 19 Del. C. 2322E requires. The report records the diagnosis, safe work capacities and modified or full-duty release. An electronic equivalent is allowed if it has every field, but office notes don't replace it.
Online, in Delaware LaborFirst. After filing, the claimant receives an access link and code for the provider, and the Certification of Serious Health Condition must be completed within 30 calendar days of the claim. It asks three questions: whether the condition meets the FMLA definition of a serious health condition, how many weeks of leave are needed, and whether reduced-schedule or intermittent leave applies. It asks for no diagnosis or records, and delegated staff can complete it.
Not anymore. As of August 2024, Delaware DMV no longer requires mandatory reporting of medical conditions, but practitioners are encouraged to report. You can send the MV-346 Physician's Findings Form with a recommendation on whether the person should drive, or request a re-examination on the MV 352 under 21 Del. C. 2714(c). Both go to the DMV Medical Section by mail, fax or email.
A Delaware-licensed MD, DO, APRN or PA completes page 2 of the patient application. Since HB 285 (2024) there is no list of qualifying conditions: the practitioner identifies any condition likely to benefit, and residents 65 or older may self-certify. The original goes in with the application within 90 days of the practitioner's signature, since fax and electronic copies aren't accepted. Patients 17 or younger need a pediatric specialist's certification.