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WDS-1(R-2-08)

Social Security Number

Claimant’s Name: _________________________________________________

PART B

MEDICAL CERTIFICATE

(TO BE COMPLETED BY YOUR DOCTOR AFTER YOU BECOME DISABLED)

1a. Patient has been under my care for this period of disability: FROM ____________________ TO __________________________

(Month/Day/Year)

b. Frequency of treatment: ___________________________________



c. Patient was last treated by me on:

__________|___________|_________

Month

Day

Year

2. Enter the date the patient was unable to perform his/her regular work due to this disability:

_________|___________|_________

Month

Day

Year

3. Estimated Recovery: (Give the approximate date patient will be able to return to work.)

_________|___________|_________

Month

Day

Year



4. If now recovered, on what date was the patient first able to work?

_________|___________|_________

Month

Day

Year

5. Diagnosis: (nature and cause of this disability which prevents patient from working) ____________________________________________

____________________________________________________________________________ ICD Code: ____________________________

Clinical data and tests to support diagnosis: _______________________________________________________________________________

6a. If pregnancy, provide estimated date of delivery:

_________|___________|_________



Month

Day

Year

b. Complications, if any.____________________________________________________

c. If pregnancy terminated, enter the date:

_________|___________|_________



Month

Day

Year

And identify the reason:

Birth

C-Section

Miscarriage

Abortion

7a. Date(s) of emergency room care or hospitalization: FROM ____________________________ TO _______________________________

b. Name and address of any specialist treating patient: ____________________________________________________________________

8. Type of surgery: ___________________________ Date of Surgery __________________ Anticipated Surgery Date _________________

Is surgery for cosmetic purposes only?

Yes

9. In your opinion, was this disability: Due to an accident at work?

Yes

Not related to his/her work

Yes

Due to a condition which developed because of the nature of the work?

Yes

10. Was this patient referred to you?

Yes

No If yes, please supply the information below if available.

Name of referring doctor _________________________________________Referring doctor’s telephone #:________________________

11. I certify that the above statements, in my opinion, truly describe the patient’s disability and the estimated duration thereof:

____________________________________________

_______________________________________

______________________

(Print Doctor’s Name and Medical Degree)

(Original Signature of Doctor Required)

(Date Signed)

____________________________________________

________________________________________ If Resident, check

(Address)

(Certificate License No. and State)

____________________________________________

(Address)

(Specialty of Treating Physician)

______________________________________________________________

(City)

(State)

(Zip Code)

Telephone Number: ( __________ )______________________________

FAX Number: ( _________ )____________________________

Disability Claim Form - State Of New Jersey Department Of Labor And Workforce Development Page 3

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