Wfnj Med 1 Form is an online form that you can use to request medical leave from your job. This form is available through the Wisconsin Family and Medical Leave Insurance (WfMLI) website. You can use this form to request a leave for your own illness or injury, or to care for a family member who is ill or injured. If you are requesting a leave for your own illness or injury, you will need to provide information about your condition. If you are requesting a leave to care for a family member, you will need to provide information about their condition. You can also use the Wfnj Med 1 Form to request an extension of a previously approved medical leave.
You will see details about the type of form you need to fill out in the table. It will show you the amount of time you will need to fill out wfnj med 1, exactly what parts you need to fill in and several additional specific facts.
Question | Answer |
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Form Name | Wfnj Med 1 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | med 1 authorization form, med 1 nj, nj med 1, med 1 forms |
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
Instructions for Completing the
The
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
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:
EXAMINATION REPORT
Patient’s Name:
WFNJ Case Number:
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Section 1 |
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Examining Healthcare Professional Name (Print): |
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Date: |
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Examining Healthcare Professional Name (Signature): |
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Professional Credential & License Number: |
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Office Address: |
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Office Phone Number: |
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Section 2 |
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Date of Patient’s Last Exam: |
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Patient’s Date of Birth: |
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Patient Diagnoses/Date of Onset: |
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Current Treatment Regimen: |
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Treatment Recommendations/Frequency: |
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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: _____ / _____ / _____ |
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☐ Refer to |
☐ Refer to SAI/BHI |
☐ Refer to SSI Project |
☐Refer to Medicaid Fraud Division
CWA/MWA Representative Name: _________________________________________________ Date:_____________