Ptax-343-A Form - Physician Statement For Exemption For Persons With Disabilities printable pdf download

Ptax-343-A Form - Physician Statement For Exemption For Persons With Disabilities

To qualify for the Homestead Exemption for Persons with Disabilities (HEPD), proof of a disability is required. The acceptable proof

of disability is listed on the back of this Form. If you are unable to provide any of these as proof of your disability, you and an Illinois

licensed physician must complete Form PTAX-343-A. You are responsible for any physicians’ costs.

Step 2:

Physician - Complete the following information

Part A: Patient information - Please print.

The patient must meet the disability criteria established by the Social Security Administration.

Note: Alcoholism or drug abuse is not included in the Social Security Administration’s guidelines as a qualiﬁcation for disability status.

Patient’s name: ____________________________________

Date patient became disabled ___ ___/___ ___/___ ___ ___ ___

Can the patient do the same type of work as prior to their disability?

Yes

6a Was the patient able to work for a living after this date?

Yes

Has the disability lasted or is it expected to continue for 12 months or more?

Yes

8 Check all

major body systems, disorders, and diseases of the patient’s disability:

Musculoskeletal

8.00

Skin

1.00

Special Senses and Speech

9.00

Endocrine

2.00

Respiratory

10.00

Impairments that Affect Multiple Body

3.00

Cardiovascular

11.00

Neurological

4.00

Digestive

12.00

Mental

5.00

Genitourinary

13.00

Malignant Neoplastic

6.00

Hematological

14.00

Immune

7.00

What is the nature of the disability? __________________________________________________________________________

Part B: Physician information

10 Name: __________________________________________

11 Your Illinois physician’s license number issued by the

0 3 6

Illinois Department of Financial and Professional Regulations:

- ___ ___ ___ ___ ___ ___

Sign below:

I have examined this patient and based on the Social Security Administration’s criteria for disability, I state that the

information contained in Step 2 is true, correct and complete to the best of my knowledge.

Physician’s signature: ___________________________________________________

Date: _____/_____/_____

Ptax-343-A Form - Physician Statement For Exemption For Persons With Disabilities

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