Disability and family leave certifications, MVC driver and placard forms, PIP auto forms, school and sports forms, and public health reports from New Jersey agencies.
New Jersey's forms come from the Department of Labor, the Motor Vehicle Commission, the Department of Banking and Insurance, the Department of Health and the courts. Clinicians meet these most: Part C of the Claim for Temporary Disability Benefits (DS-1), the MVC placard and plate application (SP-41) and temporary placard (SP-68), the Attending Provider Treatment Plan for PIP claims, the Universal Child Health Record (CH-14) and the New Jersey PPE sports physical. This page lists all 46 New Jersey forms, grouped by program.
For TDI and Family Leave Insurance claims, the provider can submit the medical statement online with the claimant's Form ID instead of the paper DS-1 or FL-1, and no fee may be charged to complete the DS-1. Employers with private plans use their carrier's form, such as MetLife's JY5334. Only providers who completed the NJDOE cardiac assessment module may sign the sports PPE. The SP-68 goes to the municipal police department, not the MVC. Spanish versions exist for 2 of these forms.
Physician report stating the medical diagnosis (and need for treatment or temporary disability) attached to a motion for medical and/or temporary benefits.
Physician statement of the petitioner's need for emergent medical care, that delay will cause irreparable harm, and the specific nature of that harm, required to support a WC-383 motion.
Certifies the patient's disability period, diagnosis/ICD code, estimated recovery date and pregnancy details for a New Jersey Temporary Disability Insurance (TDI) claim.
Certifies the family member's diagnosis/ICD code, need for full- or part-time care, first date care was needed and expected end of care for New Jersey Family Leave Insurance (FLI).
Lets the treating provider certify a longer period of disability for a claimant already approved for New Jersey TDI.
Claim for New Jersey temporary disability benefits under an employer's MetLife-insured private plan; physician certifies the sickness/injury and disability dates.
NJTDBDS1Claim for New Jersey temporary disability benefits under an employer's Guardian private plan, including the physician's certification.
Physician documents the patient's inability to work for a New Jersey temporary disability claim under an employer's private plan insured by The Standard.
Treating physician documents findings, diagnosis, and whether the member is totally and permanently disabled from assigned duties (and whether as a direct result of a work accident) for ordinary or accidental disability retirement (PERS, TPAF, SPRS and other NJDPB systems).
Treating physician documents findings, diagnosis and total and permanent disability (and work-accident causation) for a PFRS member's ordinary or accidental disability retirement.
Pre-enrollment physical examination of a new police officer or firefighter documenting history and exam findings for PFRS membership.
Physician or emergency room reports a driver's seizure or loss-of-consciousness episode (history, EEG, classification) to the MVC for medical review.
MD or DO examines a school bus driver aged 70+ (annually to 74, every six months from 75) and signs an evaluation page kept by the employer.
Medical practitioner certifies a qualifying permanent disability (limb loss, inability to walk unaided, lung disease, AHA class III/IV cardiac, etc.) for initial, recertification or replacement wheelchair-symbol plates or placard.
Medical practitioner certifies a temporary loss of limb use or mobility so the local police department can issue a temporary disability placard (up to 6 months, one recertification).
Physician or NP certification of a disability so the applicant (and a personal assistant, if needed) gets an NJ TRANSIT Reduced Fare ID.
APTP Form Version 2.1Uniform PIP form a treating provider submits to the auto insurer for decision point review or precertification of proposed treatment, diagnostic tests and durable medical equipment.
Insurer-specific assignment by which the patient directs PIP payment to the provider and the provider agrees to the insurer's decision point review/precertification plan, internal appeals and PIP dispute resolution under N.J.A.C. 11:3-5.
N.J.A.C. 11:3-25 Appendix ANotice a treating health care provider files with the PIP insurer within 21 days of starting treatment of an auto accident patient.
Version 1.2Uniform form a provider uses to appeal an auto insurer's denial or modification of a decision point review / precertification request before treatment is rendered (internal appeal required before arbitration).
Version 1.2Uniform form a provider uses to appeal an auto insurer's payment decision on PIP services already rendered (bill and line-level appeal codes).
Attending physician confirms the emergency nature of an encounter so it can be paid under the Medical Emergency Payment Program for Aliens.
Ordering provider documents the clinical reason and expected impact of a genetic or biomarker test so the lab claim can be paid.
Attending physician attests that a hospital stay was medically necessary and/or emergent for a Medicaid beneficiary.
Attending physician certifies that a Medicaid/NJ FamilyCare beneficiary is terminally ill with life expectancy of six months or less and needs hospice.
Standard health record documenting a child's physical exam, immunizations and screenings for child care centers, preschool and school entry and WIC.
State-mandated annual preparticipation physical (N.J.S.A. 18A:40-41.7) for public-school athletes; only the Medical Eligibility Form goes to the school.
Standard New Jersey form for a temporary or permanent medical exemption from school, preschool or child care immunizations, with ACIP/AAP-consistent contraindications per vaccine and a provider attestation.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Portable medical order completed jointly by a patient and practitioner documenting CPR, treatment intensity and nutrition preferences.
Documents the attending physician's compliance with the Medical Aid in Dying for the Terminally Ill Act when prescribing aid-in-dying medication.
Reports the outcome and circumstances of death of a patient who obtained medical aid-in-dying medication.
Consulting physician confirms terminal diagnosis, prognosis and capacity of a patient requesting medical aid in dying.
Mental health professional reports whether a patient requesting medical aid in dying has a condition impairing judgment.
Physician's or psychologist's certification of an alleged incapacitated person's condition and decision-making capacity, filed with a complaint to appoint a guardian (Division of Developmental Disabilities self-help kit).
Medical professional's certification of an incapacitated adult's current condition and capacity for the guardian's periodic Report of Well-Being.
Registered practitioner authorizes a patient with a qualifying condition for the medicinal cannabis registry and sets the monthly allotment.
Reports a case of a reportable communicable disease (N.J.A.C. 8:57) to the local health department; the form's own label reads 'For Reporting Reportable Communicable Diseases'.
STD-11aProvider case report of syphilis (including pregnancy, neuro/ocular/otic involvement and treatment) to the NJDOH STD Program.
STD-11bProvider case report of gonorrhea (diagnosis and treatment) to the NJDOH STD Program.
STD-11cProvider case report of chlamydial infection (diagnosis and treatment) to the NJDOH STD Program.
Reports that a patient was started on rabies post-exposure prophylaxis, with exposure type, animal, circumstances and treatment given.
State version of the CDC RVCT used to report a TB suspect or case and its initial, current and final status (diagnosis, testing, treatment, outcome).
Attending medical professional certifies life-sustaining electric equipment (use frequency, backup power, immediate danger in an outage), protecting service from disconnection for 90 days and enrolling the customer in outage notifications.
Physician attests that a summoned juror is unable to serve for 3-12+ months (or other period) so the county Jury Management Office can excuse or defer jury service.
Physician certifies that a person is blind or disabled so they can get a reduced-fee New Jersey non-driver ID (Class K).
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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Complete Part C, the Medical Certificate on page 3 of the DS-1: the disability period, diagnosis and ICD code, estimated recovery date and any pregnancy details. The claimant mails the paper claim, or you submit the online medical statement (M-01) using the Form ID on the claimant's online-filing confirmation. To extend an approved claim, use the online TDI Medical Extension (M-03). The form states that no fee may be charged to complete it.
A licensed physician, advanced practice nurse or physician assistant who has completed the NJDOE Student-Athlete Cardiac Assessment Professional Development module. The annual physical is required by state law for public-school athletes. Only the Medical Eligibility Form goes to the school; the history and exam stay with the medical home. NJDOE owns the form and NJSIAA posts it, in English and Spanish.
It is the uniform PIP form a treating provider sends to the auto insurer for decision point review or precertification of treatment, diagnostic tests and durable medical equipment. It lists diagnoses, the care path and the proposed course of treatment with CPT or HCPCS codes, frequency and duration. Fax, email or upload it to the insurer's vendor; the insurer must decide within 3 business days. Denials are appealed on the uniform Pre-Service Appeal Form.
For permanent plates or a placard, a medical practitioner, or a VA representative for disabled veterans, completes Section E of the SP-41, and the applicant attaches the practitioner's certification on a prescription or letterhead. It is mailed to the MVC Special Plate Unit. For a temporary placard, the practitioner completes Section B of the SP-68 with an NPI. The municipal police department issues it for up to 6 months, with one recertification.