PHYSICIAN’S CERTIFICATE - Md. Rule 10-202(a) - For Guardianship Evaluation

Sep 16, 2026

Physician’s Certificate CC-GN-019 (Rev. 04/2021) provides a structured form under Md. Rule 10-202(a) for clinicians to document an examination or evaluation of an alleged disabled person. It collects physician credentials, length and nature of patient relationship, in-person or remote assessment details, test/procedure information, and communication method. It also records physical and mental (DSM-5) diagnoses, severity, prognosis, medication lists, cognitive and everyday functional capacity (IADLs), and whether guardianship is medically necessary for decision-making regarding personal affairs.

LanguageEnglish

CategoryForms

FormatPDF

Pages6

Reading Time2 min

AccessFree to download

Physician’s Instructions

Physician and Patient Information

Examination/Evaluation and Diagnosis

Physical and Mental Conditions

Cognitive Function

Everyday Functioning

Institutional Care

Need for Guardianship of the Person

CIRCUIT COURT FOR , MARYLAND City/County Located at Case No. Court Address In the Matter of Name of Alleged Disabled Person Docket reference PHYSICIAN’S CERTIFICATE (Md. Rule 10-202(a)) NOTE TO PHYSICIAN: A petitioner will use this certificate in a legal proceeding to request a guardian for the patient named below. The petitioner must submit the original certificate. Your answers must be specific and detailed and based on your personal examination or evaluation of the patient. Address each issue contained in the certificate that may interfere with the patient’s ability to make responsible decisions about health care, food, clothing, shelter, or property. You may complete the form yourself or have another person fill it out under your supervision. You must sign the certificate. Your testimony about its contents may be required at a hearing. Attach additional sheets, if necessary. PATIENT’S NAME: PATIENT’S ADDRESS: PATIENT’S DATE OF BIRTH: PATIENT’S SEX: I, , employed by , Physician’s Name Employer am a Year graduate of School of Medicine. I am licensed to practice medicine in the United States in the following state(s): . My license number is: The following knowledge, training, board certification/eligibility, or experience qualifies me to examine/evaluate the patient’s functional capacity to make or communicate responsible decisions concerning their person (health care, food, clothing, shelter, etc.) or to manage their property or financial affairs: I have known this patient for Length of Time . My history of involvement with the patient is as follows: CC-GN-019 (Rev. 04/2021) Page 1 of 6 PHCER EXAMINATION/EVALUATION AND DIAGNOSIS I personally examined/evaluated the above-named patient (select all that apply): ☐ in person at (select all that apply) : ☐ a hospital/medical office/other facility, , Facility name on . Date(s) ☐ at the patient’s residence on Date(s) . ☐ other location: , located at Description Address , on Date(s) .☐ remotely, with audio and visual access to the patient, using Platform , on Date(s) . I did not meet with the patient in person because The following individual(s) assisted the patient with the virtual examination/evaluation. | Full Name | Title/Relationship | Phone Number | Email (if any) | | --- | --- | --- | --- | | | | | | | | | | | | | | | | The most recent examination/evaluation lasted approximately Length of Time . I performed or ordered the following tests and/or procedures: I communicated with the patient in the following manner: ☐ English ☐ Other language: ☐ Other means: Describe Upon examination/evaluation of the patient, I report the following findings: PHYSICAL AND MENTAL CONDITIONS Physical conditions ☐ None ☐ The patient has the following physical diagnoses: Overall physical health: ☐ Excellent ☐ Good ☐ Fair ☐ Poor Explain: Overall physical health will: ☐ Improve ☐ Be stable ☐ Decline ☐ Uncertain Explain: Mental conditions ☐ None ☐ The patient has the following mental (DSM-5) diagnoses (attach additional sheets if needed): Diagnostic Code Description | | | --- | | | | | ☐ Mild ☐ Moderate ☐ Severe Overall mental health will: ☐ Improve* ☐ Be stable ☐ Decline ☐ Uncertain *If improvement is possible, the individual should be re-examined/re-evaluated in weeks. The mental diagnosis/diagnoses affect functioning as follows: | | | --- | | | Do temporary causes of mental impairment exist? ☐ Yes ☐ No ☐ Uncertain If yes, have they been evaluated and treated? ☐ Yes ☐ No Explain: Do reversible causes of mental impairment exist? ☐ Yes ☐ No ☐ Uncertain If yes, have they been evaluated and treated? ☐ Yes ☐ No Explain: CC-GN-019 (Rev. 04/2021) Page 3 of 6 PHCER List all medications: Name Purpose Dosage/Schedule Reversible or temporary somatic factors Are there factors (hearing, vision or speech impairment, etc.) that incapacitate the patient that

FAQs

What is the purpose of the physician’s certificate under Md. Rule 10-202(a)?

The petitioner uses the certificate in a legal proceeding to request a guardian for the named patient. The physician’s answers must be specific, detailed, and based on a personal examination or evaluation.

What details must the physician provide about the examination or evaluation?

The physician must indicate whether the patient was assessed in person at a facility, at the patient’s residence, at another location, or remotely with audio and visual access. The form also requests approximate duration, tests/procedures performed or ordered, and how the physician communicated with the patient.

What functional areas does the form assess to support guardianship decisions?

It documents physical and mental conditions, including DSM-5 diagnoses and severity, cognitive impairment, and everyday functioning. It includes whether the patient can manage finances, transportation, communication, medication, and other executive functions, plus participation in civil or legal matters.

Sep 16, 2026

Uploaded by Maya Linwood