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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.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/physicians-certificate-md-rule-10-202a-for-guardianship-evaluation/280179/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/physicians-certificate-md-rule-10-202a-for-guardianship-evaluation/280179.png","ImageObject",442,249,{"name":42,"@type":43},"Maya Linwood","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-03","2026-09-16",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",34,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What is the purpose of the physician’s certificate under Md. Rule 10-202(a)?","Question",{"text":63,"@type":64},"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.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What details must the physician provide about the examination or evaluation?",{"text":68,"@type":64},"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.",{"name":70,"@type":61,"acceptedAnswer":71},"What functional areas does the form assess to support guardianship decisions?",{"text":72,"@type":64},"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.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},280179,1790196142,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":136,"language":137,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":12,"update_tm":141,"read_time":26},962084928432,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","CIRCUIT COURT FOR  , MARYLAND  \nCity/County  \nLocated at  Case No.   \nCourt Address  \nIn the Matter of  \nName of Alleged Disabled Person Docket reference  \nPHYSICIAN’S CERTIFICATE  \n(Md. Rule 10-202(a))  \nNOTE 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.  \nPATIENT’S NAME: PATIENT’S ADDRESS: PATIENT’S DATE OF BIRTH:  PATIENT’S SEX:   \nI,  , employed by  , Physician’s Name Employer  \nam 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:  \nThe 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:  \nI have known this patient for  Length of Time  . My history of involvement with the patient is as follows:  \nCC-GN-019 (Rev. 04/2021) Page 1 of 6 PHCER  \nEXAMINATION/EVALUATION AND DIAGNOSIS  \nI personally examined/evaluated the above-named patient (select all that apply):  \n☐ in person at (select all that apply) :  \n☐ a hospital/medical office/other facility,  ,  \nFacility name  \non  .  \nDate(s)  \n☐ at the patient’s residence on  Date(s)  .  \n☐ other location:  , located at  \nDescription  \n 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   \nThe following individual(s) assisted the patient with the virtual examination/evaluation.  \n\n| Full Name | Title/Relationship | Phone Number | Email (if any) |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n\nThe most recent examination/evaluation lasted approximately  Length of Time  . I performed or ordered the following tests and/or procedures:   \nI communicated with the patient in the following manner:  \n☐ English  \n☐ Other language:   \n☐ Other means:  Describe  Upon examination/evaluation of the patient, I report the following findings:  \nPHYSICAL AND MENTAL CONDITIONS  \nPhysical conditions  \n☐ None  \n☐ The patient has the following physical diagnoses:  \nOverall physical health: ☐ Excellent ☐ Good ☐ Fair ☐ Poor Explain:  \nOverall physical health will: ☐ Improve ☐ Be stable ☐ Decline ☐ Uncertain Explain:  \nMental conditions  \n☐ None  \n☐ The patient has the following mental (DSM-5) diagnoses (attach additional sheets if needed):  \nDiagnostic Code  Description  \n\n|  |\n| --- |\n|  |\n|  |\n\n☐ Mild ☐ Moderate ☐ Severe  \nOverall mental health will: ☐ Improve* ☐ Be stable ☐ Decline ☐ Uncertain  \n*If improvement is possible, the individual should be re-examined/re-evaluated in  weeks. The mental diagnosis/diagnoses affect functioning as follows:  \n\n|  |\n| --- |\n|  |\n\nDo temporary causes of mental impairment exist? ☐ Yes ☐ No ☐ Uncertain  \nIf yes, have they been evaluated and treated? ☐ Yes ☐ No Explain:   \nDo reversible causes of mental impairment exist? ☐ Yes ☐ No ☐ Uncertain If yes, have they been evaluated and treated? ☐ Yes ☐ No Explain:  \nCC-GN-019 (Rev. 04/2021) Page 3 of 6 PHCER  \nList all medications:  \nName  Purpose Dosage/Schedule  \nReversible or temporary somatic factors  \nAre there factors (hearing, vision or speech impairment, etc.) that incapacitate the patient that","cbCaibmChgs7mc4p","https://ap.wps.com/l/cbCaibmChgs7mc4p","pdf",295343,6,"English","# Physician’s Instructions\n# Physician and Patient Information\n# Examination/Evaluation and Diagnosis\n## Physical and Mental Conditions\n## Cognitive Function\n# Everyday Functioning\n# Institutional Care\n# Need for Guardianship of the Person","[{\"question\":\"What is the purpose of the physician’s certificate under Md. Rule 10-202(a)?\",\"answer\":\"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.\"},{\"question\":\"What details must the physician provide about the examination or evaluation?\",\"answer\":\"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.\"},{\"question\":\"What functional areas does the form assess to support guardianship decisions?\",\"answer\":\"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.\"}]","PHYSICIAN’S CERTIFICATE - Md. Rule 10-202(a) - For Guardianship Evaluation | PDF",1789534702]