Ma Medical Certificate – Fill Out and Use This PDF

The MA Medical Certificate form is a critical document in the Commonwealth of Massachusetts for the Probate and Family Court, used in the process of determining the appointment of a guardian and/or conservator for individuals unable to make decisions for themselves due to mental or physical incapacities. It requires detailed medical assessment by healthcare professionals, including registered physicians, licensed psychologists, certified psychiatric nurse clinical specialists, or nurse practitioners. If you or someone you know needs to fill out this form, click on the button below to get started.

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Ma Medical Certificate PDF Details

When someone's ability to make decisions for themselves becomes compromised due to mental or physical conditions, the Massachusetts Medical Certificate form for Guardianship or Conservatorship emerges as a crucial document within the Commonwealth's Probate and Family Court. This form is designed to streamline the process by which a guardian or conservator is appointed, ensuring that the individual at the center of the proceeding is provided with the necessary protection and care. Licensed healthcare professionals, including registered physicians, licensed psychologists, certified psychiatric nurse clinical specialists, and nurse practitioners, are tasked with completing this comprehensive document. It requires a meticulous evaluation of the individual's mental and physical condition, their current medication list, and their ability to manage daily living activities and make informed decisions. Moreover, the form delves into areas such as the individual's values and preferences, social networks, risks of harm, and recommendations for the level of care and supervision necessary. The ultimate goal of this process is to respect the autonomy of the individual in question as much as possible while ensuring their well-being, making the careful completion of this form a critical step in the guardianship or conservatorship proceedings. This document not only guides the court in making informed decisions but also encourages a limited guardianship or conservatorship approach, promoting the retention of the individual's rights and independence wherever feasible.

Question	Answer
Form Name	Ma Medical Certificate
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	massachusetts conservatorship form, ma guardianship form, massachusetts medical certificate, dot medical certificate ma

Form Preview Example

MEDICAL CERTIFICATE

GUARDIANSHIP OR CONSERVATORSHIP

Docket No.

Commonwealth of Massachusetts

The Trial Court

Probate and Family Court

INSTRUCTIONS FOR COMPLETION	Division

This document will be used by the Probate and Family Court in the process of determining whether to appoint a guardian and/or conservator to assume responsibility for this individual in some or all areas of decision- making and functioning. If, however, a guardianship or conservatorship is being sought for an intellectually disabled person, do not use this document. A separate Clinical Team Report is required.

To the registered physician, licensed psychologist, certified psychiatric nurse clinical specialist or a nurse practitioner completing this document:

You must complete this document. If there is any information about which you do not have direct knowledge, you are encouraged to make inquiry of such other persons as may be necessary to complete the entire form. These persons might include other healthcare professionals and/or others acquainted with the individual (e.g., family members or social service professionals). If you receive information from others, the names of those individuals must be listed in the Certification Section and attribution identified.

If you are completing this form on the computer and additional space is required for any narrative section, the section will expand to permit additional information. Do not use medical terminology and/or abbreviations without explaining them in terms that a lay person can understand.

ALL OF THE ATTACHED PAGES AND SECTIONS CONTAINED THEREIN MUST BE COMPLETED.


To the Honorable Justices of the Probate and Family Court:
The undersigned hereby certifies under the penalties of perjury that I am:
a registered physician specializing in the area of:			.
a licensed psychologist.
a certified psychiatric nurse clinical specialist.
a nurse practitioner with experience in the area of:			.

I am prepared to present a statement of my qualification to the Court by written affidavit or personal appearance if directed to do so.

I personally examined:

First NameMiddle NameLast Name(age)

who resides at

(Address Line 1)

(Apt, Unit, No. etc.)

(City/Town)

(State)

(Zip)

Date(s) of Examination(s)

Prior to examination, I informed the patient that communications would not be confidential.

Yes.

No, Explain:

MPC 400 (11/1/10) CRMDSEG

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1.CLINICALLY DIAGNOSED CONDITION(S) THAT RESULT IN INCAPACITY

A.Description of mental and physical condition

Describe the individual's mental and physical conditions necessitating the appointment of a guardian and/or conservator, including the date of onset and disease course.

B.Stability of mental and physical condition and living setting

I.In the past 90 days, has the individual's mental and/or physical condition changed?

Yes No

If yes, please explain:

Uncertain

II. In the past 90 days, has the individual's living setting (i.e. community, hospital, nursing facility) changed?

Yes No

If yes, please explain:

C. Prognosis for Improvement

Uncertain

With reasonable medical certainty, within the next 90 days, is the individual's mental and/or physical conditions likely to change substantially?

Yes

Uncertain

If yes, explain whether the condition is likely to worsen or improve, as well as if there are any aggravating factors that could make the individual appear confused but could improve with time or treatment (e.g. delirium, acute medical illness, the interaction of multiple medications, hearing loss, vision loss, bereavement, etc.):

If improvement is possible, the individual should be re-evaluated in		weeks.
D. List all Medications (or attach list):

Name	Dosage/Schedule		If an anti-psychotic medication
Name	Dosage/Schedule		indicate with a checkmark.
			indicate with a checkmark.

click to add

click to remove

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Could any of these medications impair mental functioning:

If yes, explain:

Yes

Uncertain

2. INABILITY TO RECEIVE AND EVALUATE INFORMATION OR TO MAKE OR COMMUNICATE DECISIONS

A. Alertness/Level of Consciousness

Overall Impairment:

None

Mild

Moderate

Severe

Non-Responsive

B. Memory and Cognitive Functioning (e.g., memory, comprehension, reasoning, judgment, planning, insight)

Overall Impairment:

None

Mild

Moderate

Severe

C. Emotional and Psychiatric Functioning (e.g., mood, anxiety, psychotic, substance use and other disorder)

Overall Impairment:

None

Mild

Moderate

Severe

Describe how impairments in A, B, and/or C cause the individual to have an inability to receive and evaluate information or make or communicate decisions:

3.1GUARDIANSHIP: INABILITY TO MEET ESSENTIAL REQUIREMENTS FOR PHYSICAL HEALTH, SAFETY, AND SELF-CARE

If seeking guardianship of the person, complete section 3.1. If seeking only a conservatorship, do not complete this section. Limited Guardianship is preferred by the Court; describe how the guardianship may be limited. Describe how the assessment was performed and give specific examples.

A.Areas in which the individual is able to meet the essential requirements for physical health, safety, and self-care:

Describe the individual's retained abilities and adaptive behavior for physical health, safety, self-care for which the guardianship may be limited (e.g., ability to manage ADL's and IADL's such as health, hygiene, home, communication, driving, leisure, social; functioning in the community; ability to express treatment choices and make medical decisions; ability to complete any or some legal transactions).

B.Areas in which the individual is unable to meet essential requirements for physical health, safety, or self-care: Describe the impairments in physical health, safety, and self-care for which the individual requires a guardian.

C.If individual is unable to make any decisions for him or herself or is unable to meet any essential requirements for physical health, safety, and self-care (i.e. requires a full guardianship), describe why:

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3.2 CONSERVATORSHIP: INABILITY TO MANAGE PROPERTY OR BUSINESS AFFAIRS EFFECTIVELY

If seeking conservatorship of the estate and affairs, complete section 3.2. If seeking only a guardianship of the person, do not complete this section. Limited Conservatorship is preferred by the court; describe how the conservatorship may be limited. Describe how the assessment was performed and give specific examples.

A.Areas in which the individual is able to manage property or business affairs effectively:

Describe the individual's retained abilities and adaptive behavior for management of property and estate for which the conservatorship may be limited (e.g., ability to manage allowance, bills, donations, investments, real estate, protect assets, resist fraud).

B.Areas in which the individual is unable to manage property or business affairs effectively:

Describe the impairments in the management of property and business affairs for which the individual requires a conservator. Describe how the person has property that will be wasted or dissipated unless management is provided and/or how protection is necessary to provide money for the support, care and welfare of the person or those entitled to the person's support.

C.If the individual is unable to make any decisions about, and is unable to manage, any property or business affairs effectively (i.e. requires a full conservatorship), describe why:

4.VALUES AND PREFERENCES

Describe the individual's values, preferences, and patterns, including previously described preferences (e.g., under durable power of attorney, advance directive, health care proxy, or living will documents), whether the individual accepts or opposes the guardianship/conservatorship, where the individual prefers to live, what makes life meaningful for the individual, and religious or cultural considerations.

5.SOCIAL NETWORKS AND RISK OF HARM TO SELF OR OTHERS

A.Social Network Relationships Social Support (Check one)

Very good supportive network

Social Skills (Check one)

Very good social skills

B.Nature of Risks

Some support from family and friends

Good social skills

Limited or nonexistent support

Poor social skills

Describe the significant risks facing this individual and specify whether these risks are due to this individual's condition and/or due to another person harming or exploiting him or her:

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C.	The individual's risk of harm to self or others is:		Mild	Moderate	Severe
D.	The likelihood of harm is:	Almost Certain	Probable	Possible	Unlikely

6.RECOMMENDATIONS FOR LEVEL OF CARE/SUPERVISION NEEDED, INCLUDING HOUSING A. An institutional placement being pursued at the following:

Nursing home/Rehabilitation

Psychiatric facility

Other facility

None

If none, skip to section 7; if yes, answer:

Uncertain

B. The individual requires the following level of supervision:
Locked facility	24 hr. supervision	Some	None
Less restrictive placement options have been pursued:
Yes	No	Uncertain
The placement is anticipated to be:
Long-term	Short-term	Uncertain

Describe the specific reasons for placement and efforts made to preserve the person's social support system (e.g. placement in community of residence or near family):

7. RECOMMENDATIONS FOR APPROPRIATE TREATMENT AND HABILITATION: The individual may benefit from:

Educational potential, training, or rehabilitation	Yes	No	Uncertain
Technological assistance or accommodations	Yes	No	Uncertain
Mental health treatment	Yes	No	Uncertain
Occupational, physical, or other therapy	Yes	No	Uncertain
Home and/or social services	Yes	No	Uncertain
Medical treatment, operation or procedure	Yes	No	Uncertain
Other:
Describe any specific recommendations:

8. ATTENDANCE AT HEARING

It would be clinically harmful for the individual to attend the hearing. Describe why:

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The individual is able to attend the court hearing

What accommodations, if any, would enable the individual to attend the hearing:

9. CERTIFICATIONS

This form was completed based on an in-person clinical evaluation of the individual:

who

is not a patient under my continuing care and treatment.

In addition to a clinical examination, other sources of information for this examination:

Review of medical record.

Discussion with health care professionals involved in the individual's care.

Discussion with family or friends.

Other

Names and titles/relationships of those individuals who assisted in preparation of this report:

Name	Title/Relationship

	click to add	click to remove
List any tests which bear upon the issues of incapacity and date of tests:

Test	Date

click to add

click to remove

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This document must be signed and dated by the person completing it. It does not need to be notarized.

I hereby certify that the evaluation of diagnosis, cognition, and function is within the scope of my professional competence based upon my education, training, and experience. I further certify that this report is complete and accurate to the best of my information and belief.

Signed under the penalties of perjury:

Date

SIGNATURE OF CLINICIAN

(Print name)

License type, number, and date

Office Address:

(Address)

(Apt, Unit, No. etc.)

(City/Town)

(State)

(Zip)

Office Phone:

Reset Form

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