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MEDICAL CERTIFICATION LOGIN

Welcome to the New Jersey Division of Temporary Disability Insurance medical extension application. This application allows healthcare providers to enter the necessary medical information to extend a patient’s temporary disability benefits.

Please enter the online form ID and your patient's date of birth below to continue.

Enter the Online Form ID :
(This number can be found in block 4 of the medical extension instructions)
Enter your patient's date of birth :		(MM/DD/YYYY)