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NJ FD-80 Emergency Medical Condition Certification

New Jersey Medicaid requires this signed hard-copy attachment when a claim under the Medical Emergency Payment Program for Aliens involves a diagnosis that corresponds with urgent care under N.J.A.C. 10:49-5.4. The attending physician records the diagnosis, treatment and dates, then checks whether the condition does or does not meet the emergency medical condition definition in section 1903(v) of the Social Security Act.

Who completes it

The attending physician completes the clinical section, checks does or does not, and signs with a license number. The applicant or beneficiary signs the release at the bottom allowing DMAHS to request the treatment information.

Submitting and payment

How to submit it
Attach the signed hard copy to the claim sent to Gainwell Technologies; it is a paper attachment, not an online form.

Good to know

  • The definition printed on the form covers acute symptoms severe enough that, without immediate care, health would be in serious jeopardy or bodily functions or organs seriously impaired.
  • The physician must choose one box, does or does not, so the form can also document that a condition did not qualify as an emergency.
  • The patient's signature authorizes DMAHS to request emergency treatment information and the physician or facility to provide it for the eligibility decision.
  • The printed version is FD-80 (11/98); a separate letter-style Emergency Certification Form is used to certify that a hospital stay was medically necessary or emergent.

Get the official form

Download the current version from the source each time; forms change without notice.

Certification of Treatment of Emergency Medical Condition

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

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.

Frequently asked questions

When is NJ form FD-80 required?

When an application or claim under the Medical Emergency Payment Program for Aliens involves a diagnosis that corresponds with urgent care under N.J.A.C. 10:49-5.4. In those cases DMAHS requires this hard-copy attachment, signed by the attending physician, confirming the emergency nature of the encounter.

Who signs the FD-80?

Two people sign. The attending physician signs with a license number and printed name after checking whether the condition meets the section 1903(v) emergency definition. The applicant or beneficiary signs a separate authorization allowing DMAHS to request information about the emergency treatment for the eligibility decision.