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Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
The PAF must be completed annually to provide medical certification that the client has a diagnosis that meets the CSHCN Services Program’s definition of a child with special health-care needs. Ensure each section is complete. An incomplete PAF will be rejected.
Important considerations that should be used when referring clients to the program:
- The primary diagnosis must indicate that the client meets the CSHCN Services Program’s definition of a child with special health-care needs, identifies the urgent need for care, or both.
- The primary diagnosis on the PAF must be a chronic condition with physical manifestations and not solely a delay in intellectual, mental, behavioral, or emotional development.
- Any additional diagnoses may be listed in the “Additional ICD Code” sections.
- For example, if a CSHCN Services Program client has a diagnosis of autism and cerebral palsy, use cerebral palsy as the primary diagnosis because it indicates a physical disability, and autism does not.
- Provide a valid code from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code (or its successor) that indicates an applicant’s chronic physical condition.
- Use ICD-10 Codes that ensure the highest level of specificity. Use the full diagnosis code, including any suffixes (e.g., “D51.2” rather than “D51”).
- The form should be signed by a physician (Doctor of Medicine [MD], Doctor of Osteopathy [DO], Doctor of Dental Surgery [DDS], Doctor of Dental Medicine [DMD]), Advanced Practice Registered Nurse [APRN], or physician assistant [PA] who has seen the client in the previous 12 months.
- The signature must be an original signature or an electronic signature. Stamped signatures and signatures that have been typed in a document without using an electronic identifier will not be accepted.
- If physician assistant or advanced practice registered nurse completes and signs the PAF they must provide the name and NPI number of their supervising physician.