Problem Forms & Order Forms


Problem Forms

  • (Revised January 2107) Family members and staff may use this form when a person with an intellectual and developmental disability is having difficulty obtaining Medicaid.

  • Family members and staff may use this form if an individual is currently enrolled in a Medicaid HMO and is having difficulty obtaining a medical, dental, or behavioral health service that should be covered by the HMO. This form can also be used with the HMO has reduced the approved number of hours of a service (e.g., person care assistant services or private duty nursing).


Order Forms

  • The Arc of New Jersey’s Diabetes Awareness and Education Project has produced materials intended to educate individuals with developmental disabilities and their caregivers regarding important steps that can be taken toward the prevention and control of Diabetes, including changes in diet and exercise habits and regular monitoring by a health care professional.

  • The Arc of New Jersey’s highly regarded educational film, Let’s Talk About Health: What Every Woman Should Know, designed to help women with cognitive disabilities learn more about their bodies and what to expect when they go to the doctor for a gynecological exam; available in DVD and workbook


Health & Wellness Forms

Adult Personal Health Record and Medical History Form
With a grant from the New Jersey Council on Developmental Disabilities, The Arc of New Jersey has developed a new Adult Personal Health Record and Medical History Form, available in both English and Spanish. Completed by a family member or caregiver, the form provides accurate documentation of the most important aspects of a person’s medical history. The original remains with the consumer or caregiver; a copy can be provided to the consumer’s primary health care providers; and copies can be brought when the consumer has other health appointments, such as a clinic or emergency room.

  • Adult Personal Health Record and Medical History Form: English
  • Adult Personal Health Record and Medical History Form: Spanish

Cancer Screening and Risk Reduction
The Arc of New Jersey and its Mainstreaming Medical Care Program have developed an initiative called Let's Talk About Health, which is a comprehensive effort to develop educational programs and materials that address health care issues of people with developmental disabilities in accesible formats. Projects to date include the following:

Diabetes Materials
Launched in 2006 with funding from The Horizon Foundation for New Jersey, The Arc of New Jersey’s Diabetes Awareness and Education Project has produced materials intended to educate individuals with developmental disabilities and their caregivers regarding important steps that can be taken toward the prevention and control of Diabetes, including changes in diet and exercise habits and regular monitoring by a health care professional. Read More...

To Order a Copy of the Diabetes Booklet and/or Educational Film, Click Here.

Diabetes Video Guide and Booklet (English Version):

Diabetes Video Guide and Booklet (Spanish Version):

Women's Health Project