New Jersey workers claim state Temporary Disability Insurance for their own illness, injury or pregnancy with the DS-1. Part C, the Medical Certificate on page 3, is where the treating provider certifies the disability period, diagnosis with ICD code and estimated recovery date. The Division of Temporary Disability and Family Leave Insurance uses it to decide benefits.
The claimant completes Part A (personal and disability information) and Part B (all employers in the past six months); the patient's licensed healthcare provider completes and signs Part C.
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Claim for Temporary Disability Benefits (Part C - Medical Certificate)
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No. Part C of the DS-1 states that N.J.S.A. 12:18-1.6 prohibits charging a fee to complete the form. The rule is printed directly above the medical certificate that the provider fills in for a state Temporary Disability Insurance claim.
When the claimant applies online, they receive a unique Form ID and give the provider printed instructions. The provider enters the TDI medical statement (M-01) on the Division's secure website with that Form ID and gets immediate confirmation, so no paper Part C is needed.
Part C asks for the first and most recent treatment dates and visit frequency, the date the patient became unable to do regular work, the recovery date or an estimated return-to-work date, and any emergency room, hospitalization or surgery dates. The instructions call for exact dates, never 'present' or 'current'.