NJ DDD Annual Physical Form: Form F5, Signatures, and Submission

The NJ DDD annual physical form, officially the “Medical Form for Adults” (Form F5), is a two-page document that a caregiver starts and a physician finishes: you fill in identifying information, medical history, and current medications before the appointment, the doctor completes the labs, clinical exam, and signature at the visit, and the signed form goes to your Support Coordinator, who uploads it to the Division’s iRecord system.

Where To Get Form F5

The New Jersey Department of Human Services publishes Form F5 as a PDF on the Division of Developmental Disabilities section of NJ.gov.¹ Your Support Coordinator can email you a copy if the link gives you trouble. Print it single-sided; the physician needs room to write on both pages.

Is the Physical Required for Your Situation

New Jersey Administrative Code requires an annual medical examination for every individual living in a licensed DDD residential setting.² If the individual lives at home or in another non-licensed setting, including situations where they only attend a day program or receive other waiver services, the annual physical is not mandated by regulation but is “highly recommended” by the Division, and Support Coordinators are expected to raise it during monitoring visits.³ Most Support Coordination Agencies treat a current physical as a baseline for building the annual Individualized Service Plan, so a skipped exam can still cause friction even without a direct penalty.

What the Caregiver Completes Before the Appointment

The top of page one collects the individual’s name, age, date of birth, sex, health insurance number, Social Security number, and the date of the exam.¹ Fill in everything except the exam date before you leave the house; the provider records that at the visit.

Section A: Medical History

Section A has three parts the caregiver completes in advance:

Present and past medical conditions, including any history of communicable diseases. Be specific. “Epilepsy, tonic-clonic, diagnosed 2014” is more useful than “seizures.”
Previous hospitalizations and surgeries, with dates and reasons.
Immunizations, including the date of the most recent adult diphtheria/tetanus booster and all three Hepatitis B dates if the individual has received them. The form notes that if the last tetanus booster was more than ten years ago, the physician should administer one.

Bring the individual’s immunization records or a printout from their primary care office. Missing immunization dates are one of the most common reasons a form comes back incomplete, and one of the easiest to fix ahead of time.

Section D: Medications

The form gives space for five medications. For each, list the drug name, dosage, how often it is taken, and the medical reason for the prescription.¹ If the individual takes more than five, attach a pharmacy printout. Make sure the list matches the pharmacy’s records; a discrepancy can flag a safety concern during the coordinator’s review.

What the Physician Completes at the Visit

Section B covers laboratory tests: an annual Mantoux (TB) skin test for non-reactors (a Tine test is not acceptable, and a positive reactor is never retested), a Hepatitis B profile at the initial exam, a blood lead level for individuals with pica behavior or for those entering or leaving a developmental center within the specified windows, and a comprehensive metabolic panel, CBC, urinalysis, and serology at the initial exam with repeat frequency at the physician’s discretion. A Pap smear follows American Cancer Society guidelines, and an EKG is done initially at age 40 with repeats at the physician’s discretion.

Section C documents seizures and their frequency and type, special dietary needs (a written diet prescription must be attached if one is required), allergies and sensitivities, and any behavioral or psychiatric disorders.

Section E is the hands-on clinical examination. The physician records vital signs and findings across fifteen body systems, notes any activity restrictions, and issues prescriptions for medication, diet, adaptive equipment, procedures, and therapies. The physician then prints their name, signs, and dates. A form without a signature and date is invalid.

Because the Mantoux test requires a return visit 48 to 72 hours later for the reading, schedule the appointment early enough that the result can be entered on the form before your submission deadline.¹

Who Can Sign the Form

The New Jersey Administrative Code refers to “the examining physician,” and the signature line is labeled for a physician.² MDs and DOs both qualify. New Jersey law also authorizes Advanced Practice Nurses and Physician Assistants to perform physical examinations under their scope of practice, and many Support Coordination Agencies accept forms signed by APNs or PAs. Confirm with your Support Coordinator before booking with a non-physician provider so you don’t end up repeating the visit.

How To Submit the Completed Form

Deliver the signed form to your assigned Support Coordinator. The coordinator confirms that every required field is legible and that the provider signature is valid, then uploads the form to iRecord, the Division’s electronic case management system.³ Most agencies accept scanned PDFs by secure email or through an agency portal. Ask which method your coordinator prefers and whether they require a specific file-naming convention.

If the coordinator finds gaps, they will return the form. The most common hold-ups are missing lab results (especially the Mantoux reading), an unsigned or undated form, and medication entries that list a drug without dosage or frequency. Check those three things before you leave the doctor’s office.

When the Physical Is Due

Annual documents in the DDD system expire at the one-year mark, and a valid physical should always be on file.³ The Division expects that no individual in a licensed residential setting goes more than twelve months without a professional medical review.²

When a new Individualized Service Plan is generated, whether because of a reassessment, a waiver transition, or retirement, all annual documents must be re-obtained and signed even if the current ones have not yet expired.³ For a new admission to a licensed residential program, the physical must have been completed within 90 days before the scheduled admission date.²

Book the appointment at least 60 days before the current physical expires. That window covers the Mantoux return visit, lab turnaround, any corrections the coordinator flags, and the upload to iRecord. Letting a physical lapse in a licensed setting puts the residence out of compliance with N.J.A.C. 10:44A and can trigger a deficiency finding during a state licensing review.

Asking for Accommodations During the Exam

Individuals with developmental disabilities are entitled to reasonable modifications during the physical under the Americans with Disabilities Act and Section 1557 of the Affordable Care Act. Providers must communicate as effectively with patients with disabilities as with any other patient, which may include large-print materials, extra appointment time, or a sign-language interpreter.⁴ If the individual has sensory sensitivities, difficulty staying still, or anxiety around medical procedures, tell the office when you schedule. Many practices will offer a quieter exam room, keep a caregiver in the room throughout, or break the appointment into shorter segments.

The office must also have accessible medical equipment when readily achievable, meaning it can be done without significant difficulty or expense relative to the practice’s size and resources.⁴ If the individual uses a wheelchair, confirm ahead of the visit that the office has an accessible exam table and a scale that accommodates a wheelchair. Accurate height and weight belong in the clinical examination section, and improvised measurements invite errors that come back for correction.

1
New Jersey Department of Human Services. New Jersey Division of Developmental Disabilities Medical Form for Adults
2
New Jersey Office of Licensing. NJAC 10:44A Standards for Community Residences for Individuals With Developmental Disabilities
3
New Jersey Department of Human Services. ISP Plan Reviews: Guidance for Support Coordination Agencies
4
ADA.gov. Businesses That Are Open to the Public