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Affirmation (Certification) Of Examining Physician (SCPA Article 17-A) GMD-2B - New York

Affirmation (Certification) Of Examining Physician (SCPA Article 17-A) Form. This is a New York form and can be used in Guardianship Surrogates Court Statewide .
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SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF _________________________ --------------------------------------------------------------------X Proceeding for the Appointm ent of a Guardian for AFFIRM ATION (CERTIFICATION) OF EXAM INING PHYSICIAN File No. _______________________________ Pursuant to SCPA Article 17-A --------------------------------------------------------------------X STATE OF NEW YORK ) COUNTY OF ) ss.: I, __________________________________________________________, a physician duly licensed to practice m edicine in the State of New York, under penalty of perjury affirm s as follows: [PLEASE ANSW ER ALL QUESTIONS] 1. 2. My license num ber is : ______________________________________________________________________ My offices are located at: ____________________________________________________________________ ___________________________________________________________________________________________ 3. My professional knowledge and/or background in the care and treatm ent of persons with [ disabilities [ ] developm ental disabilities is as follows: ] intellectual ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4(a). I have exam ined the Respondent on: [Set forth date(s).] ___________________________________________________________________________________________ (b). [Check appropriate box(es) and explain where requested]: [ ] I have perform ed the following tests or evaluations of the Respondent. [Set forth in detail the names of tests and/or evaluations, dates perform ed and results.] ____________________________________________________________________________________ ____________________________________________________________________________________ [ ] I have reviewed the following tests or evaluations perform ed on Respondent. [Set forth in detail the nam es of tests and/or evaluations, dates performed, results and names of doctors who performed the tests and/or evaluations.] ____________________________________________________________________________________ ____________________________________________________________________________________ GMD-2B (7/2016) -1- American LegalNet, Inc. www.FormsWorkFlow.com 5. The m ental and physical condition of the Respondent is as follows: [Describe in detail.] ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 6. [Check appropriate box(es)]: INTELLECTUALLY DISABLED [ ] Based upon the foregoing, it is m y conclusion the Respondent is an intellectually disabled person and in m y opinion incapable of m anaging him self/herself and/or his/her affairs by reason of intellectual disability. The nature and degree of the intellectual disability is as follows: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ DEVELOPMENTALLY DISABLED [ ] Based upon the foregoing, it is m y conclusion that the Respondent is developm entally disabled and in m y opinion he/she has an im paired ability to understand and appreciate the nature and consequences of decisions, which results in Respondent being incapable of m anaging him self/herself and/or his/her affairs by reason of developm ental disability, and whose disability is attributable to: [ ] (a) Cerebral palsy, which originated before the Respondent attained the age of twenty-two. [Describe, in detail, the nature, degree and origin of the disability.] ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ [ ] (b) Epilepsy, which originated before the Respondent attained the age of twenty-two. [Describe, in detail, the nature, degree and origin of the disability.] ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ [ ] (c) Neurological im pairm ent, which originated before the Respondent attained the age of twenty-two. [Describe, in detail, the nature, degree and origin of the disability.] ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ -2- American LegalNet, Inc. www.FormsWorkFlow.com [ ] (d) Autism , which originated before the Respondent attained the age of twenty-two. [Describe, in detail, the nature, degree and origin of the disability.] ______________________________________________________________________________ ______________________________________________________________________________ [ ] (e) Traum atic head injury. [Describe, in detail, the nature, degree and origin of the disability.] ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ [ ] (f) A condition, which originated before the Respondent attained the age of twenty-two, found to be closely related to an intellectual disability, because such condition results in sim ilar im pairm ent of general intellectual functioning or adaptive behavior to that of intellectually disabled persons. [Describe in detail the condition, and the nature, degree and origin of the disability.] ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ [ ] (g) Dyslexia resulting from a disability descri
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