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Stamped signatures and signatures that have been typed in a document without using an electronic identifier will not be accepted. The signature must be an original signature or an electronic signature.The form should be signed by a physician (Doctor of Medicine, Doctor of Osteopathy, Doctor of Dental Surgery, Doctor of Dental Medicine ), Advanced Practice Registered Nurse, or physician assistant who has seen the client in the previous 12 months.Use the full diagnosis code, including any suffixes (e.g., “D51.2” rather than “D51”). Use ICD-10 Codes that ensure the highest level of specificity.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.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.Any additional diagnoses may be listed in the “Additional ICD Code” sections.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.

Important considerations that should be used when referring clients to the program: 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.