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The WFNJ Med 1 form plays a pivotal role in the intersection of healthcare and public assistance in New Jersey. Specifically designed to assess an individual’s ability to comply with the work participation requirement of the Work First New Jersey (WFNJ) program, the form is essential for those seeking a medical deferral due to health issues. When recipients of WFNJ assistance request such a deferral, healthcare professionals must provide thorough documentation based on an in-person evaluation. This Examination Report requires input from a licensed physician, psychologist, midwife, or advanced practice nurse, ensuring that a qualified professional evaluates the individual’s condition. Sections within the form collect key information, including medical credentials and specific clinical details about the patient's health status and treatment. Moreover, the report must clarify whether the patient can engage in various work activities, acknowledging that these activities vary significantly in physical and psychological demands. If an individual is unable to participate, the healthcare professional must also provide insights on the expected duration of their limitations. This comprehensive approach helps safeguard benefits while acknowledging the nuances of each person's health needs. Failure to return the completed form within the stipulated timeframe can lead to significant consequences, including potential loss of assistance, underscoring the importance of this document in the broader social safety net.

Wfnj Med 1 Example

The individual named on the reverse side of this form has requested a medical deferral from the work participation requirement of the Work First New Jersey (WFNJ) program (New Jersey’s public financial assistance program) due to a reported medical condition. Recipients of WFNJ assistance are required to participate in a “work activity.”

Completion of the Examination Report (WFNJ-MED-1 form) is required in order to determine whether the individual is able to participate in a work activity or meets the criteria for a medical deferral from the WFNJ work requirement due to his/her medical condition. The information supplied in the Examination Report must be based on an actual in-person evaluation of the patient by the examining healthcare professional.

Instructions for Completing the WFNJ-MED-1

The WFNJ-MED-1 form must be completed by a licensed physician, psychologist,

midwife or advanced practice nurse, as appropriate.

Section 1: In completing this section, the examining healthcare professional must supply his/her name, signature, professional credential, license number, office address, and phone number.

Section 2: In completing this section, the healthcare professional must supply all clinical information requested and indicate whether the patient is able to participate in a work activity.

The WFNJ program offers a diverse set of work activities in which individuals can participate. Work activities require varying levels of physical and psychological capability and include full-time employment, volunteer activities, vocational training, and educational activities, among others. Therefore, please consider the range of work activities available when assessing the level to which an individual may be able to participate, as opposed to simply stating that the individual is able/unable to participate in work activities in general.

Lastly, if it is determined that the individual is not currently able to participate in a work activity, please indicate, relative to prognosis and treatment regimen, when the individual will be well enough to participate.

If the fully completed form is not returned to our office within 30 days, the individual will be expected to participate in a work activity, and is subject to loss of his/her public assistance benefits if he/she does not participate in the work activity. Please send the completed form directly to the office indicated below. Please do not return the completed form to the client.

Agency:

Special Instructions:

WFNJ-MED-1 (Rev. 1/15)

WFNJ-MED-1 (Rev. 1/15)

EXAMINATION REPORT

Patient’s Name:

WFNJ Case Number:

 

 

Section 1

 

 

Examining Healthcare Professional Name (Print):

 

 

Date:

 

 

 

 

 

 

 

 

Examining Healthcare Professional Name (Signature):

 

 

 

 

 

 

 

 

 

 

 

Professional Credential & License Number:

 

 

 

 

 

 

 

 

 

 

 

Office Address:

 

 

 

 

 

 

 

 

 

 

 

Office Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 2

 

 

Date of Patient’s Last Exam:

 

Patient’s Date of Birth:

 

 

 

 

 

 

 

 

Patient Diagnoses/Date of Onset:

 

 

 

 

 

 

 

 

 

 

 

ICD-9-CM/DSM-5 Codes:

 

 

 

 

 

 

 

 

 

 

 

Current Treatment Regimen:

 

 

 

 

 

 

 

 

 

 

 

Treatment Recommendations/Frequency:

 

 

 

 

Does the patient require behavioral health/substance abuse treatment? Yes ☐ No ☐

Do any of the above diagnoses limit the patient’s ability to participate in gainful employment and/or occupational training? Yes ☐ No ☐

If yes, please specifically explain how the diagnoses limits the patient’s ability to participate in gainful employment and/or occupational training (ex. unable to stand for long periods of time, unable to lift objects, etc.):

Is the patient able to engage in any gainful employment and/or occupational training of any kind? Yes ☐ No ☐

If No – Please specify the date when you expect that the patient will be able to engage in any gainful employment

and/or occupational training._____ /_____ /_____

Do you expect the patient’s barriers to employment/training to last longer than 6 months ☐ 12 months ☐ ?

County/Municipal Welfare Agency Use

☐ Approved Deferral start date: _____ / _____ /_____

Deferral end date: _____ / _____ / _____

Incomplete-Requested additional information from provider on _____ /_____ /_____

☐ Refer to One-Stop

☐ Refer to SAI/BHI

☐ Refer to SSI Project

Refer to Medicaid Fraud Division

CWA/MWA Representative Name: _________________________________________________ Date:_____________

Form Characteristics

Fact Name Description
Purpose of the Form The WFNJ MED-1 form is used to request a medical deferral from the work participation requirement for the Work First New Jersey (WFNJ) program based on a reported medical condition.
Required Evaluation An in-person evaluation is mandatory for the completion of the Examination Report. This ensures that the information provided is accurate and reliable.
Eligibility Assessment The form helps determine if the individual can participate in various work activities depending on their medical condition, rather than simply stating they are either able or unable to work.
Eligibility for Professionals A licensed physician, psychologist, midwife, or advanced practice nurse must complete the form, ensuring that a qualified healthcare professional is providing the evaluation.
Treatment Recommendations Healthcare professionals must provide information about the patient's current treatment regimen and recommendations for the frequency of treatment.
Response Deadline The completed form must be submitted within 30 days. If not received in time, the individual may be required to participate in work activities and risk losing their benefits.
Intake Details Specific sections on the form ask for important details, such as the patient's diagnosis, treatment, and limitations affecting their ability to engage in work or training.
Client Instruction It is critical that the completed form is sent directly to the agency indicated on the form, and not returned to the client to prevent any delays or issues with processing.
Governing Law The WFNJ program operates under New Jersey state laws, established to provide financial assistance to residents in need.

Guidelines on Utilizing Wfnj Med 1

Filling out the WFNJ Med 1 form is a crucial step for individuals seeking a medical deferral from work participation requirements. It's essential to ensure that every section is completed accurately, as this impacts the evaluation of the individual's ability to engage in work activities.

  1. Section 1 - Healthcare Professional Information:
    • Print the name of the examining healthcare professional.
    • Provide the date of the examination.
    • Sign the form as the examining healthcare professional.
    • List your professional credential and license number.
    • Fill in the office address.
    • Provide the office phone number.
  2. Section 2 - Patient Evaluation:
    • Record the date of the patient's last exam.
    • Note the patient's date of birth.
    • Outline the patient’s diagnoses and the date of onset.
    • Include the applicable ICD-9-CM or DSM-5 codes.
    • Describe the current treatment regimen.
    • Provide treatment recommendations and frequency.
    • Indicate if the patient requires behavioral health or substance abuse treatment (Yes/No).
    • Determine if the patient’s diagnoses limit their ability to participate in work (Yes/No), and if so, explain how.
    • Assess if the patient can engage in any form of gainful employment or training (Yes/No).
    • If No, specify the expected date when the patient will engage in this activity.
    • Indicate if the patient's barriers to employment or training are expected to last longer than 6 months or 12 months.
  3. Final Steps:
    • Send the completed form directly to the indicated office. Ensure that it is done within 30 days.
    • Do not return the completed form to the client.

Once the form is filled out and submitted appropriately, the individual can expect an evaluation of their situation based on the clinical information provided. This evaluation will play a vital role in determining the next steps in their participation in work activities and the possible approval of their medical deferral.

What You Should Know About This Form

What is the purpose of the WFNJ Med 1 form?

The WFNJ Med 1 form is used to request a medical deferral from the work participation requirement in New Jersey's Work First New Jersey (WFNJ) program. When an individual claims a medical issue, this form helps assess whether they can engage in any work activities or if a medical deferral is justified based on their condition.

Who is qualified to complete the WFNJ Med 1 form?

A licensed healthcare professional, such as a physician, psychologist, midwife, or advanced practice nurse, must complete the WFNJ Med 1 form. This ensures that the evaluation is conducted by someone with the appropriate professional credentials and experience.

What information is required in Section 1 of the form?

In Section 1, the examining healthcare professional must provide their name, signature, professional credentials, license number, office address, and phone number. This information helps verify the identity and qualifications of the person conducting the evaluation.

What should be included in Section 2 of the form?

Section 2 requires detailed clinical information about the patient, including the date of their last exam, date of birth, current diagnoses, and treatment regimen. The professional must also indicate whether the patient can participate in work activities, along with a prognosis for their ability to work in the future.

What happens if the form is not submitted within 30 days?

If the fully completed form is not returned to the WFNJ office within 30 days, the individual will be expected to participate in a work activity. Failing to comply may result in loss of public assistance benefits.

What types of work activities are considered under the WFNJ program?

The WFNJ program includes a variety of work activities such as full-time employment, volunteer positions, vocational training, and educational programs. These activities are designed to accommodate different levels of physical and psychological capability.

What should be done if additional information is needed?

If the WFNJ office requires more information regarding the case, they will request clarification or additional details from the healthcare provider. It is important for the provider to respond promptly to ensure that the assessment can be completed.

Can someone still work if a medical deferral is granted?

While a medical deferral indicates that a recipient is not currently able to engage in work activities, the individual may still seek employment in a capacity that aligns with their medical recommendations. The deferral is specifically related to the work participation requirement of the WFNJ program.

How does the WFNJ Med 1 form affect public assistance beneficiaries?

The WFNJ Med 1 form is crucial for beneficiaries as it determines their eligibility for a medical deferral. If the form demonstrates a valid medical condition preventing work participation, the beneficiary may continue to receive assistance without the obligation to participate in work activities.

Common mistakes

Completing the WFNJ-MED-1 form is a critical step for individuals seeking a medical deferral from work participation requirements. However, mistakes made in filling out this form can lead to significant delays or denials of assistance. One common mistake is not providing complete contact information for the examining healthcare professional. Section 1 requires the individual's name, signature, professional credentials, license number, office address, and phone number. Failing to include any of these details can result in the form being deemed incomplete.

Another frequent error involves inadequate clinical information in Section 2. This section needs a thorough assessment of the patient's condition, including diagnoses, treatment regimens, and the impact on work participation. Simply stating whether a patient is able or unable to engage in work activities without elaborating on their specific limitations does not provide the necessary detail for decision-makers. The reviewing agency depends on clear and specific explanations to evaluate the medical deferral request adequately.

Additionally, some healthcare professionals neglect to project when the patient might be able to return to work if they are currently unable to participate in any gainful employment. The form specifically asks for expectations regarding the duration of the patient's inability to work. By not specifying a timeline, it becomes challenging for the welfare agency to make informed judgments regarding the patient's future eligibility for assistance.

Lastly, a lack of timely submission can lead to severe consequences. The complete form must be returned within 30 days; otherwise, the individual risks automatic participation in work activities. Failure to comply can result in the loss of public assistance benefits. It is essential that individuals ensure the form is filled out comprehensively and submitted promptly to avoid these mistakes that could hinder their access to necessary support.

Documents used along the form

The WFNJ Med 1 form plays a crucial role in determining an individual’s eligibility for a medical deferral from work activities under the Work First New Jersey program. However, it's often accompanied by several other forms and documents that further support the process and provide necessary information. Below is a list of such documents commonly used alongside the WFNJ Med 1 form.

  • WFNJ-MED-2 Form: This form is typically filled out by the healthcare provider to document the specific medical condition and its impact on the individual’s capacity to work. It includes detailed clinical observations and treatment recommendations.
  • Case Management Plan: This document outlines the strategies and interventions planned for the client. It helps ensure that all stakeholders understand the goals and services necessary for the individual’s well-being and success.
  • Individualized Education Plan (IEP): For clients under 22, the IEP may be needed to document educational accommodations. It details the student’s learning needs and the adjustments required to support their educational progress.
  • Social Security Administration Medical Records: These records can provide insight into an individual’s disability claims and health status. They help establish a comprehensive view of the person’s medical history.
  • Supplemental Nutrition Assistance Program (SNAP) Application: Individuals may need to apply for SNAP, which ensures they have access to food resources while they navigate their work participation requirements.
  • Referral Documentation: This could include referrals to job training programs or other support services. These documents are essential for aligning the individual with appropriate resources and opportunities.
  • Psychological Evaluation Report: If mental health issues are a factor, this report provides detailed insights from a licensed professional regarding the individual’s psychological condition and its impact on their ability to work.

Understanding these accompanying documents equips individuals and their advocates to navigate the WFNJ program more effectively. Each form contributes valuable information and facilitates a comprehensive assessment of the individual’s ability to engage in work activities, ensuring that everyone receives the support they deserve.

Similar forms

The WFNJ Med 1 form plays a crucial role in determining eligibility for work participation exemptions due to medical conditions. Several other documents have similar functions, focusing on verifying an individual’s medical status and eligibility for various assistance programs. Here’s a list of those documents:

  • Disability Determination Services (DDS) Application: This form evaluates a person’s disability status to qualify for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), requiring medical evidence similar to the WFNJ Med 1.
  • Employment Support Services (ESS) Medical Clearance Form: Used to assess whether an individual can perform specific job functions, this document requires an assessment by a healthcare professional, similar to the WFNJ Med 1.
  • Worker’s Compensation Medical Report: This form is submitted after a workplace injury to confirm the employee's ability to return to work. It serves a similar purpose by documenting medical conditions affecting work capacity.
  • Family Medical Leave Act (FMLA) Certification: This document requires healthcare provider input on whether an employee has a serious health condition, paralleling the medical assessment process in the WFNJ Med 1 form.
  • Veterans Affairs Disability Benefits Questionnaire: This questionnaire collects medical information to assess a veteran’s disability and eligibility for benefits, reflecting similarities in its medical evaluation requirements.
  • State or Local SNAP Medical Exemption Form: Used to request exemptions from work requirements in the Supplemental Nutrition Assistance Program (SNAP), this form also necessitates a medical assessment like the WFNJ Med 1.
  • Medicaid Eligibility Determination Form: This form includes medical assessments to determine eligibility for Medicaid, paralleling the need for medical documentation in the WFNJ Med 1.
  • Social Security Administration (SSA) Paperwork for Disability: This includes various forms that require medical evidence to establish disability status for benefits, operating on principles similar to those in the WFNJ Med 1.

Dos and Don'ts

Filling out the WFNJ MED-1 form correctly is crucial for individuals seeking medical deferrals from work requirements. Here are five things to keep in mind:

  • Do provide accurate information. Ensure that all details about the patient, including their diagnoses and treatment, are precise.
  • Don't forget to sign and date the form. It’s important that the healthcare professional’s signature, name, and date are included in Section 1.
  • Do include specific details about limitations. Clearly explain how the patient’s medical condition affects their ability to participate in work activities.
  • Don't leave sections incomplete. Every section should be filled out to avoid delays in processing the request.
  • Do send the completed form directly to the specified office. Avoid returning the form to the client as it may result in setbacks.

By following these guidelines, you can help ensure a smoother process for those in need of assistance.

Misconceptions

Here are six common misconceptions about the WFNJ MED 1 form along with clarifications to help better understand its purpose and requirements.

  • Anyone can complete the form. Only licensed healthcare professionals such as physicians, psychologists, midwives, or advanced practice nurses are authorized to fill out the WFNJ MED 1 form. Their professional evaluation is essential to provide accurate and valid information.
  • The form guarantees a medical deferral. Completing the WFNJ MED 1 form does not automatically ensure that an individual will receive a medical deferral from work participation requirements. The information on the form is reviewed to determine eligibility based on specific criteria.
  • It is acceptable to send the form back to the client. After completion, the WFNJ MED 1 form must not be returned to the client. Instead, it should be sent directly to the appropriate office as indicated in the instructions.
  • Any medical condition qualifies for a deferral. Not all medical conditions will lead to a deferral. The specific nature of the individual's condition must be assessed in relation to their ability to participate in various work activities.
  • The evaluation doesn't need to be in-person. The Evaluation Report must be based on an in-person examination. This ensures that healthcare professionals can assess the individual's condition accurately and provide the necessary details regarding their abilities and limitations.
  • The completion timeline is flexible. It is crucial to submit the completed form within 30 days. If it is not submitted by this deadline, the individual may be required to participate in work activities, which could affect their public assistance benefits.

Key takeaways

When filling out and utilizing the WFNJ Med 1 form, several important factors should be considered to ensure proper completion and submission. Here are some key takeaways to keep in mind:

  • Purpose of the Form: The WFNJ Med 1 form is intended to determine whether an individual can be medically deferred from participating in work activities as part of the Work First New Jersey (WFNJ) program.
  • Eligibility: Only licensed healthcare professionals—such as physicians, psychologists, midwives, or advanced practice nurses—should complete the form.
  • Detailed Information Required: The examining healthcare professional must provide comprehensive details in the Examination Report, including their name, credentials, signature, and contact information.
  • Clinical Assessment: It’s essential that the information supplied is derived from an actual, in-person evaluation of the patient.
  • Work Activities Consideration: Assess the patient’s ability to participate in a range of work activities, from full-time employment to volunteer opportunities. Avoid generalizations when determining their capabilities.
  • Prognosis Insight: If a medical deferral is warranted, indicate when the patient is expected to become capable of participating in work activities based on their treatment plan.
  • Submission Timeline: The completed form must be submitted to the relevant office within 30 days, or the individual may lose their public assistance benefits.
  • Direct Submission: Do not return the completed form to the client. Instead, ensure it is sent directly to the designated office.
  • Comprehensive Explanations: If the patient’s capabilities are limited, clearly explain how their diagnoses restrict them from engaging in work or training activities.
  • Follow-Up Requirements: Be aware that if additional information is needed, the welfare agency will request it from the provider.

By considering these takeaways, healthcare professionals can contribute to a thorough evaluation process, helping ensure that individuals get the appropriate assessments they need concerning their work participation requirements.