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MPC 403 (11/1/10)    AFMEDMEDICAL CERTIFICATE AFFIDAVITCommonwealth of Massachusetts The Trial Court Probate and Family Court Docket No.The purpose of this affidavit is to obviate the need for a new medical certificate for patients who have been and continue to be medically stable as indicated on the most recently filed Medical Certificate, particularly Part I, A & B.  This may not be used at the time of a permanent appointment unless counsel for the Incapacitated or Protected Person has been appointed and does not object to its use.Divisiona registered physician specializing in the area of:a licensed psychologist.a certified psychiatric nurse clinical specialist.The undersigned hereby certifies under the penalties of perjury that:To the Honorable Justices of the Probate and Family Court:I am:a nurse practitioner with experience in the area of:..Last NameMiddle NameFirst NameI personally examined:Date(s) of Examination(s)onand reviewed the most recently filed medical certificatedated.Based upon this examination and review, I certify that the prior diagnosis and statements regarding decision-making and functional abilities contained in the most recently filed medical certificate continue to be true and accurate and are incorporated and merged herein. (age)The individual is presently under my continuous care, with regular treatment and observation sinceThere have been no significant changes in the individual's diagnoses, decision-making, or functional abilities in the interim period.The individual has resided in the same setting and has had no acute medical admissions in the interim period or, if there has been a medical admission, this admission did not affect the individual's prior diagnosis, decision-making or functional abilities.I hereby certify that the evaluation of diagnosis, cognition, and function is within the scope of my professional competence based upon my education, training, and experience.  I further certify that this report is complete and accurate to the best of my information and belief.(date).SIGNATURE OF CLINICIANDate(Print name)License type, number, and dateOffice Phone: (Address Line 1)(City/Town)(State)(Zip)(Apt, Unit, No. etc.)Office Address: Signed under the penalties of perjury:

Medical Certificate Affidavit

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Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.mass.gov (2023-03)
Page(s): 1
Fields(s): 24
Average fields per page: 24
Reading Level: Grade 40
LIST Grouping(s): HE-03-00-00-00, HE-00-00-00-00.

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

form_body_page_text_field__1 was form1[0].BodyPage1[0].S1[0].TextField4[0] (0.59 conf)
form_body_page_drop_list was form1[0].BodyPage1[0].S1[0].DropDownList1[0] (0.37 conf)
form_body_page_field__1 was form1[0].BodyPage1[0].S2[0].#field[0] (0.41 conf)
form_body_page_field__2 was form1[0].BodyPage1[0].S2[0].#field[1] (0.41 conf)
form_body_page_field__3 was form1[0].BodyPage1[0].S2[0].#field[2] (0.41 conf)
form_body_page_text_field__2 was form1[0].BodyPage1[0].S2[0].TextField4[0] (0.41 conf)
form_body_page_text_field__3 was form1[0].BodyPage1[0].S2[0].TextField4[1] (0.41 conf)
form_body_page_field__4 was form1[0].BodyPage1[0].S2[0].#field[5] (0.41 conf)
form_body_page_text_field__4 was form1[0].BodyPage1[0].S3[0].TextField4[0] (0.41 conf)
form_body_page_text_field__5 was form1[0].BodyPage1[0].S3[0].TextField4[1] (0.41 conf)
form_body_page_text_field__6 was form1[0].BodyPage1[0].S3[0].TextField4[2] (0.41 conf)
form_body_page_text_field__7 was form1[0].BodyPage1[0].S3[0].TextField4[3] (0.41 conf)
form_body_page_date_time_field__1 was form1[0].BodyPage1[0].S3[0].DateTimeField2[0] (0.40 conf)
form_body_page_text_field__8 was form1[0].BodyPage1[0].S3[0].TextField4[4] (0.41 conf)
form_body_page_date_time_field__2 was form1[0].BodyPage1[0].S4[0].DateTimeField1[0] (0.40 conf)
form_body_page_date_time_field__3 was form1[0].BodyPage1[0].S5[0].DateTimeField3[0] (0.40 conf)
form_body_page_text_field__9 was form1[0].BodyPage1[0].S5[0].TextField4[0] (0.41 conf)
form_body_page_text_field__10 was form1[0].BodyPage1[0].S5[0].TextField4[1] (0.41 conf)
form_body_page_text_field__11 was form1[0].BodyPage1[0].S5[0].TextField4[2] (0.41 conf)
form_body_page_text_field__12 was form1[0].BodyPage1[0].S5[0].TextField4[3] (0.41 conf)
form_body_page_text_field__13 was form1[0].BodyPage1[0].S5[0].TextField4[4] (0.41 conf)
form_body_page_text_field__14 was form1[0].BodyPage1[0].S5[0].TextField5[0] (0.41 conf)
form_body_page_text_field__15 was form1[0].BodyPage1[0].S5[0].TextField4[5] (0.41 conf)
form_body_page_text_field__16 was form1[0].BodyPage1[0].S5[0].TextField4[6] (0.41 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Medical Certificate Affidavit

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Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02