Form 3034, Physician/Dentist Assessment

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Effective Date: 11/2021


Updated: 7/2021

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.