The 57 Massachusetts forms clinicians complete, from PFML certifications and RMV medical forms to MassHealth and insurer prior authorization, the MOLST and Section 12.
This page lists the Massachusetts forms clinicians complete, grouped by program, and each group links to its program hub. Paid Family and Medical Leave brings the DFML Certification of Your Serious Health Condition and its family member version, plus private plan forms from Unum and Guardian. The RMV uses MAB106 for medical evaluations, MAB108 after loss of consciousness and MAB100 for disabled parking. Insured health plans use the Division of Insurance standard forms for medication and imaging prior authorization, and MassHealth has its own General Drug request.
Workers' comp has no treating-clinician form; the DIA impartial physician writes a narrative report. For PFML, the provider can send the certification straight to DFML or return it to the patient to upload. The School Health Record exam form covers school entry and grades 1, 4, 7 and 10. MassHealth's paper PA-1 is only for providers with a paper waiver. A Section 12 hold starts on form AA-5. Of these forms, 6 have a Spanish version. Vero Documents fills PDF forms from the visit note and the chart.
DIA-appointed impartial physician's report on medical end result, permanent impairment, extent and duration of disability, and whether the work injury is the major or predominant cause.
PFML-FORM-Cert-SHCCertifies the employee's own serious health condition (incl. pregnancy/post-birth recovery) that prevents them from working and its probable duration, for Massachusetts paid medical leave.
Health care provider certification of a serious health condition (own or family member) for an employer's Unum-insured private plan under Massachusetts Paid Family and Medical Leave.
PFML-FORM-Cert-Family-SHCCertifies that the employee's family member has a serious health condition requiring the employee's care, with the type, frequency and duration of care, for Massachusetts paid family leave.
CL-1297-MAHealth care provider documentation of a child's birth and parent's relationship for bonding leave under a Unum-insured Massachusetts PFML private plan.
Care recipient's health care provider certifies the serious health condition for a Massachusetts family leave claim under a Guardian private plan.
Claim for Massachusetts paid medical leave under a Guardian private plan; the doctor certifies the period of care and incapacity.
Treating physician's statement, required by 840 CMR 10.06(1)(b), on incapacity, permanence and causation (accidental, ordinary, presumption, violent act injury) for a Massachusetts public employee's disability retirement application to one of the 104 local retirement boards.
Certificate completed by the PERAC regional medical panel physicians after examining a disability retirement applicant, answering incapacity, permanence and causation questions (variants for accidental, ordinary, heart, lung, cancer presumptions etc.).
Eye doctor's certification that a Class D/M applicant meets RMV minimum visual standards, used in place of the RMV vision test.
MAB106Physician's evaluation of a driver's medical fitness to drive when the RMV has requested a medical evaluation, certified under penalty of perjury.
Lets a medical provider or law enforcement official report a person believed no longer physically and/or cognitively capable of driving safely.
Physician's evaluation of a seizure or other loss/alteration of consciousness episode, including any request to waive the standard six-month no-driving period.
Medical examination certifying that an applicant meets the medical standards for a 7D school pupil transport or school bus driver certificate.
Eye doctor's certification that a Class A/B/C permit or license applicant meets FMCSA vision standards.
MAB105Applies for a Massachusetts-only intrastate CDL medical waiver (540 CMR 14.05) for conditions such as vision, hearing, limb or diabetes that fail federal standards.
Psychiatric evaluation of whether a mental health condition impairs a driver's ability to operate a motor vehicle safely.
Endocrinologist's evaluation of an insulin-treated diabetic applicant for a school bus or 7D driver certificate, with glucose-monitoring conditions.
Physician's cardiovascular evaluation of an applicant for a school bus or 7D driver certificate.
Certifies a disability category so the applicant can receive a Transportation Access Pass (TAP) reduced-fare CharlieCard.
Applies for a temporary or permanent disability placard, disability plate or disabled veteran plate, with the healthcare provider's clinical diagnosis and certification of severe mobility restriction.
Additional information from the applicant's health care provider that the MBTA Mobility Center may request when deciding ADA paratransit (The RIDE) eligibility.
General MassHealth pharmacy prior authorization request for drugs on the MassHealth Drug List without a class-specific form.
Combined prescription and medical necessity review for DME and medical supplies, required with MassHealth DME PA requests and claims.
Member's primary care provider documents diagnoses and functional needs so the member can be evaluated for MassHealth personal care attendant (PCA) services.
Medical necessity certification for non-emergency ambulance or wheelchair van transport of a MassHealth member.
MassHealth fee-for-service prior authorization request for medical services, DME and other services requiring PA.
PCP order certifying that a member needs Adult Foster Care services.
Standard provider examination form shared with the school to document the physical examinations required by M.G.L. c.71 s.57 (school entry, grades 1, 4, 7, 10).
Medical examination required for family child care licensees, certified assistants and household members caring for children in a licensed family child care home.
Medical clearance required by 105 CMR 201 before a student removed from an extracurricular athletic activity for a head injury or suspected concussion may return to practice or competition.
DPH-recommended pediatric TB risk assessment for school-aged children, documented on the school health form, to identify children who need TB infection testing.
Written medical exemption documenting a contraindication to a required vaccine for school, child care, camp or college entry under 105 CMR 220.000.
Medical order form relaying a seriously ill patient's decisions on CPR, ventilation, hospital transfer and other life-sustaining treatment across care settings.
Section 12(a) application by a clinician who examined the person and believes hospitalization is needed to avoid likelihood of serious harm, and Section 12(b) authorization by the admitting designated clinician (3-day hold).
Clinician's certificate of a person's clinically diagnosed condition, functional limitations and incapacity, used by the court to decide whether to appoint a guardian and/or conservator (and for Rogers antipsychotic authority).
Clinician's certificate that a person under guardianship or conservatorship no longer meets the standard, supporting termination.
MPC 402Report of a clinical team (physician, licensed psychologist and social worker) required to appoint or continue a guardian for a person with an intellectual disability.
Short clinician affidavit confirming a person remains medically stable as described in the most recent Medical Certificate, avoiding a new MPC 400.
Certifying healthcare provider executes an electronic certification that the patient has an active debilitating medical condition and that benefits likely outweigh risks, setting duration (15 days to 1 year) and 60-day quantity.
Electronic provider case reports for gonorrhea, syphilis, HIV/AIDS, TB (positive IGRA/TST or suspected active TB), varicella, hepatitis B in pregnancy/infants, alpha-gal syndrome and facility clusters.
Mandated reporter's written report of suspected child abuse or neglect under M.G.L. c.119 s.51A, following the required phone report.
Mandated reporter's written report of suspected abuse, neglect, financial exploitation or self-neglect of a community-dwelling adult aged 60+.
Provider report of congenital syphilis, neonatal herpes or ophthalmia neonatorum in an infant.
Medical, rehabilitation or service-agency professional certifies that a household member has a disability (fair housing definition) and explains the disability-related need for the requested accommodation in public housing or the leased housing (Section 8) program.
Doctor's letter certifying that a summoned juror cannot perform 6 hours/day of sedentary attentive work for 3 days, giving a 3-year (standard) or lifetime (permanent) disqualification under G.L. c. 234A, s. 4.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The employee's health care provider: an MD or DO, dentist, podiatrist, chiropractor, clinical psychologist, optometrist, NP, nurse-midwife, clinical social worker, PA or Christian Science practitioner. The provider answers questions 7 to 15 on the condition and its probable duration, then faxes it to DFML or returns it for the patient to upload. Employers with a Unum or Guardian private plan use that insurer's form instead.
On MAB100, the provider completes Sections D and E with a Board of Registration in Medicine number and NPI. Symptoms such as pain, or ICD codes alone, are rejected as a diagnosis, asthma alone does not qualify, and lung disease needs PFTs. A physician must also say whether the patient is medically qualified to drive. The original is mailed to RMV Medical Affairs; faxes are not accepted.
Side 1 of form AA-5, the Section 12(a) application, is signed by a Massachusetts-licensed physician, licensed psychologist, APRN or LICSW who examined the person and believes hospitalization is needed to avoid a likelihood of serious harm. Side 2, the Section 12(b) authorization for a 3-day hold, is signed by a designated physician or qualified APRN at the admitting facility. The form travels with the person.
The instructions recommend bright pink paper, but photocopies, faxes and electronic copies are all valid. A physician, NP or PA signs the orders with the patient or representative, and the signed form stays with the patient. Massachusetts is moving to the National POLST model with an ePOLST Registry in spring 2027, after which new orders are created in the registry. Existing MOLSTs stay valid.