Published 02/2017, CN 12042 (Certification of Examining Professional) Instructions: Certification of Examining Professional If you are a guardian of the person, you may be required to file a Report of Well-Being which includes a Certification of Examining Professional. The Certification of Examining Professional is a form certification which should be provided to a medical professional (i.e., medical doctor (M.D.), doctor of osteopathic medicine (D.O.), etc.) who has performed a recent medical evaluation of the incapacitated person. 1. At the top left of the form, enter your name, address, and daytime phone number. 2. On the line above In the Matter of: fill in the full legal name of the incapacitated person. 3. Provide this form to the examining professional to fill out the remainder of the form. Additional pages may be attached if more space is needed. Note: If the examining professional wishes to utilize his/her own form, make sure that their statement addresses all of the information contained in this form. American LegalNet, Inc. www.FormsWorkFlow.com Published 02/2017, CN 12042 (Certification of Examining Professional) Certification of Examining Professional Name: Address: Telephone: In the Matter of: ( Insert the incapacitated person's name) , an Incapacitated Person. I, , of full age, hereby certify as follows: 1. This certification is made by me for purposes of the periodic report of the well - being of , an incapacitated person . [insert the incapacitated person222s name] 2. I examined , on . The e xamination took place at [in sert the incapacitated person222s name] [insert date ] . My examination revealed that (select one) the condition of the incapacitated person is essentially unchanged ; during the reporting period, the condition of the incapacitated person has changed as follows: 3. In my opinion, , [insert the incapacitated person222s name] continues to lack capacity to govern him/herself and to manage his/her affairs to the same extent and therefore the guardianship should continue unchanged; exhibits a change in capacity such that the guardianship should be modified as follows: I hereby certify and say that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment . Date Signature of Professional Print Name American LegalNet, Inc. www.FormsWorkFlow.com