Form Pa-1000 Ps - Physician'S Statement - 2016
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116 531
59
Physician’s Statement
Physician’s Statement
of Permanent and
Total Disability
PA-1000 PS (08-16)
PA Department of Revenue
2016
OFFICIAL USE ONLY
Name as shown on PA-1000
Social Security Number
START
Instructions
A claimant not covered under the federal Social Security Act or the federal Railroad Retirement Act who is unable
to submit proof of permanent and total disability may submit this Physician’s Statement. The physician must deter-
mine the claimant’s status using the same standards used for determining permanent and total disability
under the federal Social Security Act or the federal Railroad Retirement Act. CAUTION: If the claimant applied
for Social Security disability benefits and the Social Security Administration did not rule in the claimant’s favor,
the claimant is not eligible for a Property Tax or Rent Rebate.
Confidentiality Statement. All information on this Physician’s Statement and claim form is confidential. The
department shall only use this information for the purposes of determining the claimant’s eligibility for a Property
Tax or Rent Rebate.
CERTIFICATION
I certify the claimant named above is my patient and is permanently and totally disabled under the standards that
the federal Social Security Act or the federal Railroad Retirement Act requires for determining permanent and total
disability. Upon request from the PA Department of Revenue, I will provide the medical reports or records indicat-
ing diagnosis and prognosis of the claimant’s condition, including signs, symptoms and laboratory findings, if
applicable or appropriate.
Please sign after printing.
Physician Signature
Date
MM/DD/YY
Description of Claimant’s Permanent and Total Disability. Briefly describe the reason(s) the above-named
claimant is totally and permanently disabled.
Physician Identification Information. Please print.
Name
National Provider Identifier
Business name, if applicable
Address
City
State
ZIP Code
Office telephone number
Office email address
16 531
59
1605310059
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