Official Site of The State of New Jersey
Learn more about our programs, and find out how to complete and submit patient forms.
Complete Patient Forms Online
Complete Patient Forms Online
Temporary Disability Insurance provides cash benefits to employees in New Jersey who are unable to work due to a physical or mental health condition or other disability unrelated to their work, including pregnancy/child birth recovery. Click here to download a printable handout about the program.
As a medical professional, you determine whether your patient’s physical or mental health condition prevents them from being able to work. When completing the medical certification, clearly state the diagnosis and certify the first day of disability.
Only an approved healthcare provider can attest to the diagnosis on the application for Temporary Disability Insurance benefits (Form DS-1). If you are a certified physician’s assistant (PA-C), your supervising physician must provide their name and medical license number on the certification.
If your patient applied online for benefits, they will provide you with printed instructions for completing your medical statement (form M-01) online. This sheet also provides the patient’s unique Form ID, which you will need to complete your medical certification using our online system. Once your patient provides you with the online Form ID, submit the medical section within 14 days of the request or claim processing could be significantly delayed.
The information you submit is encrypted, and the system meets all state-mandated security standards. You’ll get immediate confirmation that we received your statement.
We strongly encourage you to submit your medical certification online because it's faster for your patient. If your patient applies using a paper application, or you to prefer to submit a paper statement, complete part C of the application for Temporary Disability Insurance benefits (Form DS-1) and fax it to 609-984-4138 or mail it to Division of Temporary Disability Insurance, P.O. Box 387, Trenton, NJ 08625-0387.
Expectant mothers may be eligible for Temporary Disability Insurance benefits while they are pregnant and after they deliver. In most cases, a pregnancy disability period starts four weeks before the expected delivery date and ends six weeks after the birth (or eight weeks after a Cesarean section), but the duration can vary depending on the medical evaluation of the mother’s condition.
For pregnancy complications that arise more than four weeks before the estimated due date, be sure to explain the disabling condition experienced by the mother (e.g., preeclampsia, gestational diabetes, multiple gestation, etc.). Simply indicating a general need for bed rest is not sufficient.
Once your patient delivers, you will need to complete a supplemental medical form stating the date of delivery, whether or not it was a C-section, and the expected date of full recovery. You must also note any applicable complications that will extend your patient’s recovery period beyond the customary six to eight weeks after the birth, or past your estimate on the original claim form. If your patient is experiencing any complication that is not within your scope of practice, refer them to an approved healthcare provider who specializes in that area. The patient should get a certification of disability from that specialist.
While you are treating a patient for any non-pregnancy-related health condition, you’ll need to periodically complete a supplemental medical form so we know that the patient remains in your care and still cannot work. You will also need to submit this form when your patient has recovered and can return to work.
To protect the integrity of the disability benefits fund, we verify claims and review diagnosis (ICD) codes and the applicant’s estimated date of recovery. We use this information to determine whether it is consistent with the normal anticipated duration of the claimed illness, injury, or other disability.
Your patient may be unable to work due to conditions that require treatment from other health care providers. You can only certify for conditions that are within the scope of your practice.
By applying for Temporary Disability Insurance benefits, patients authorize their doctors to share their medical information with the Division of Temporary Disability Insurance. We will not contact you to discuss your patient’s condition without express written authorization. If we need to verify your patient’s extended illness or disability period, we may contact you by telephone or mail.
The Division of Temporary Disability Insurance is not a “covered entity” under the federal Health Information Portability & Accountability Act (HIPAA). Except to the extent necessary to administer the Temporary Disability Benefits Law, all of your medical records are confidential and are not open to public inspection. We protect all records that may reveal the identity of your patient.
Family Leave Insurance provides cash benefits to employees in New Jersey who are unable to work because they need to bond with a new child, care for a family member with a physical or mental health condition, or handle matters related to domestic or sexual violence. Workers can collect Family Leave Insurance benefits for a maximum of twelve consecutive weeks in a 12-month period, or up to eight weeks (56 individual days) in a 12-month period, if taking leave in a non-continuous manner. Click here to download a printable handout about the program.
As an approved health care provider, only you can determine whether your patient’s physical or mental health condition requires physical care or emotional support from a family member. In some cases, more than one person may receive family leave benefits to care for the same family member.
Only a health care provider licensed to provide health care services under federal, state, or local law or the laws of a foreign nation, or any other person who is authorized by a licensed health care provider to provide health care, can certify the serious illness on the application for Family Leave Insurance benefits.
If your patient applied online for benefits, they will provide you with printed instructions for completing your medical statement (form M-01) online. This sheet also provides the patient’s unique Form ID, which you will need to complete your medical certification using our online system.
Once the applicant provides you with the online Form ID, submit the medical section within 14 days of the request or claim processing could be significantly delayed for your patient's caregiver.
The information you submit is encrypted, and the system meets all state-mandated security standards. You’ll get immediate confirmation that we received your statement.
We strongly encourage you to submit your medical certification online because it's faster for your patient or your patient's caregiver. If your patient or their caregiver applies using a paper application or you prefer to submit a paper statement, complete part C of the application for Family Leave Insurance form (FL-1) and fax it to 609-984-4138 or mail it to Division of Temporary Disability Insurance, P.O. Box 387, Trenton, NJ 08625-0387.
Individuals may be eligible for Family Leave Insurance benefits to bond with a newborn, newly adopted, or newly placed foster child during the first 12 months after the child’s birth or placement. To bond with a newborn, workers must be the baby’s biological parent, or the biological parent’s domestic partner or civil union partner. Bonding leave can be taken all at once in one consecutive 12-week period, or a day at a time up to 56 individual days (eight weeks). Medical documentation is not required for bonding claims.
Individuals may be eligible for Family Leave Insurance benefits to care for a family member with a serious physical or mental health condition. A health care provider must certify the condition and that the patient requires care. Family caregivers may take their leave all at once in one consecutive 12-week period, or a day at a time up to 56 individual days (eight weeks) during the 12-month period starting with the first date of leave.
The definition of family member is generous and includes:
- parents
- spouse
- children of any age
- parents-in-law
- siblings
- grandparents
- grandchildren
- domestic partners
- civil union partners
- any other individuals related by blood
- any other individuals with whom you consider to be family
A “serious health condition” means an illness, injury, impairment, or physical or mental condition that requires inpatient care in a hospital, hospice, or residential health care facility, or continuing treatment or continuing supervision by a health care provider.
If your patient's caregiver did not initially claim their maximum family leave entitlement, and your patient now needs ongoing care or support, the family caregiver (the person applying for benefits) will give you a form "Family Leave Insurance Continued Claim Information (FL3)" so you can certify the need for continued care.
To protect the integrity of the family leave benefits fund, we verify claims and review diagnosis (ICD) codes and the care recipient’s estimated date of recovery. We use this information to determine whether it is consistent with the normal anticipated duration of the claimed illness, injury, or other disability.
When a caregiver applies for Family Leave Insurance benefits, the family member receiving care must authorize his or her health care providers to share medical information with the Division of Temporary Disability & Family Leave Insurance. We will not contact you to discuss your patient’s condition without express written permission. If we need to verify your patient’s extended illness or disability period, we may contact you by telephone or mail.
The Division of Temporary Disability & Family Leave Insurance is not a “covered entity” under the federal Health Information Portability & Accountability Act (HIPAA). Except to the extent necessary to administer the Temporary Disability Benefits Law, all of your medical records are confidential and are not open to public inspection. We protect all records that may reveal the identity of your patient.
Frequently Asked Questions
Get answers to common questions about our programs, and how to submit patient information to us.
Unique Patient Situations
Some diagnoses require more details from the healthcare provider. Find out what they are, and what information we need.
Download Patient Brochures
Use our free, printable information pages to keep your patients informed about our programs.
How to Complete a Medical Statement
We explain step-by-step how to submit a patient's proof of disability, or need for caregiving by a family member.
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Form Lookup
This page lists all the Temporary Disability and Family Leave Insurance forms that we send, why we send them, and what to do if you get one.
