5339 form-2026

1. Click ‘Get Form’ to open the 5339 form in the editor.
2. Begin by filling out Section 1 with the child's information, including their name, date of birth, height, weight, and gender.
3. In Section 2, document any information received by you as the physician. List consulted persons and tests performed related to the child's evaluation.
4. Proceed to Section 3 where you will detail diagnosed conditions and symptoms. Ensure to specify medications recommended along with dosages and expected treatment duration.
5. Complete Section 4 by recommending any additional services or treatments necessary for the child’s care.
6. In Section 5, certify if a delay in medication could cause significant harm to the child. Provide a detailed explanation if applicable.
7. Finalize by signing in Section 9, certifying that all medical information has been reviewed and discussed with the child’s guardian.

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