Form 3034, Provider Assessment Form

Instructions

Updated: 1/2025

The Provider Assessment Form (PAF) must be completed yearly to provide medical certification that a client has a diagnosis that meets the CSHCN Services Program’s definition of a child with special health care needs. Make sure each section is complete. An incomplete PAF will be rejected.

Important considerations when referring clients to the program or submitting an application for renewal:

• Provide a current and 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.
  • Note: Submitting outdated or incorrect ICD codes can lead to delays in processing a patient’s application, denial of a patient’s application, even if they have an approved diagnosis, or financial burdens for both providers and clients.
• Use ICD-10 Codes that ensure the highest level of specificity. Use the full diagnosis code, including any suffixes such as D51.2 rather than D51.
• The primary diagnosis must indicate 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, autism does not.
• The PAF must be signed by the client’s evaluating provider who is a 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), and who has personally evaluated the client no more than 12 months before the application submission.
• The signature must be an original signature or an electronic signature that produces a date and time stamp. Stamped signatures and signatures that have been typed in a document without an electronic identifier will not be accepted.
• If a PA or APRN completes and signs the PAF, they must provide the name and NPI number of their supervising physician.