MedicaidAdministrativeMedium impact
Newsletter Vol. 12, No. 61
New Jersey Medicaid·NJ·Provider Notice
Effective date
Jul 1, 2002
We identified it
Jun 20, 2026
Summary
New Jersey has updated the Patient Certification Form (FD-197) for Medicaid/NJ FamilyCare/CSOCI programs. Providers must immediately begin using the revised form or create their own form containing all required elements per state regulations.
Action Required
Immediately: Replace existing Patient Certification Forms with the new FD-197 (Rev. 7/02) or create provider-designed forms containing all elements required by N.J.A.C. 10:49-9.9(a). Forms must include beneficiary name, Medicaid ID number, date of service, service description, and beneficiary signature. Keep forms on file for each service and make available upon request. Contact Division's Office of Provider Enrollment at (609) 588-2905 for form approval questions.