Instructions: Certification of Examining Professional
If you are a guardian of the person, you may be required to file a Report of Well-Being which includes a Certification of Examining Professional. The Certification of Examining Professional is a form certification which should be provided to a medical professional (i.e., medical doctor (M.D.), doctor of osteopathic medicine (D.O.), etc.) who has performed a recent medical evaluation of the incapacitated person.
If you are a guardian of the person, you may be required to file a Report of Well-Being which includes a Certification of Examining Professional. The Certification of Examining Professional is a form certification which should be provided to a medical professional (i.e., medical doctor (M.D.), doctor of osteopathic medicine (D.O.), etc.) who has performed a recent medical evaluation of the incapacitated person.
-
At the top left of the form, enter your name, address, and daytime phone number.
-
On the line above In the Matter of: fill in the full legal name of the incapacitated person.
-
Provide this form to the examining professional to fill out the remainder of the form. Additional pages may
be attached if more space is needed.
Published 02/2017, CN 12042 (Certification of Examining Professional)
Name:
Address:
Telephone:
In the Matter of: (Insert the incapacitated person's name)
an Incapacitated Person.
Telephone:
In the Matter of: (Insert the incapacitated person's name)
an Incapacitated Person.
,
Certification of Examining Professional
I, , of full age, hereby certify as follows:
1. This certification is made by me for purposes of the periodic report of the well-being of
1. This certification is made by me for purposes of the periodic report of the well-being of
[insert the incapacitated person’s name]
, an incapacitated person.
2. I examined , on
[insert the incapacitated person’s name]
My examination revealed that (select one)
the condition of the incapacitated person is essentially unchanged;
during the reporting period, the condition of the incapacitated person has changed as follows:
My examination revealed that (select one)
the condition of the incapacitated person is essentially unchanged;
during the reporting period, the condition of the incapacitated person has changed as follows:
. The examination took place at
[insert date]
.
.
3. In my opinion,
,
[insert the incapacitated person’s name]
continues to lack capacity to govern him/herself and to manage his/her affairs to the same extent and therefore the guardianship should continue unchanged;
exhibits a change in capacity such that the guardianship should be modified as follows:
I hereby certify and say that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment.
Date
Signature of Professional
Print Name
continues to lack capacity to govern him/herself and to manage his/her affairs to the same extent and therefore the guardianship should continue unchanged;
exhibits a change in capacity such that the guardianship should be modified as follows:
I hereby certify and say that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment.
Date
Published 02/2017, CN 12042 (Certification of Examining Professional)
