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SECTION II – TO BE COMPLETED BY CERTIFYING PHYSICIAN

WHEN DID THE BORROWER’S PRESENT ILLNESS OR INJURY START?

WHEN DID THE BORROWER BECOME UNABLE TO WORK AND EARN MONEY?

_______/_________/_________

DIAGNOSIS OF BORROWER’S PRESENT MEDICAL CONDITION.

NATURE OF ONSET

CURRENT MEDICATIONS

REHABILITATION PLANS (Include any treatment which has not been accepted by the Borrower)

□

BORROWER IS

AMBULATORY;

BED CONFINED;

HOUSE CONFINED;

HOSPITAL CONFINED;

OTHER______________________________________________

□

PROGNOSIS – IS CONDITION STATIC?

YES

NO IF “NO”, WHAT OPTIMUM IMPROVEMENT CAN BE EXPECTED

PHYSICIAN CERTIFICATION OF BORROWER’S TOTAL AND PERMANENT DISABILITY

I certify that in my best professional judgment (borrower’s __________________________________________________________________________________________________is unable to

engage in any substantial gainful activity or attend school because of a medically determinable impairment that is expected to continue for a long and indefinite period of time or to result in death.

I am legally authorized to practice in the State of __________________________________________.

10.

NAME & ADDRESS OF PHYSICIAN (Print or type)

11.

DATE

_______/_________/_________

12.

SIGNATURE OF PHYSICIAN (M.D. OR D.O.)

SECTION III – TO BE COMPLETED BY LENDER

(Borrower and Physician leave blank)

LENDER NAME

LENDER ADDRESS

TOTAL AMOUNT OF UNPAID BALANCE

DATE PREPARED BY LENDER

YYYY

$_______________________________________

__________/_________/___________

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Privacy Act Notice

The Privacy Act of 1974 (5 U.S. C. 522a) requires that an agency provide the following notice to each individual whom it asks to supply information.

The authority for collecting the information requested on this form is found in Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 294m)

and the Consolidated Appropriations Act, 2014.

The principal purposes of this information are to verify the identity of the borrower; eligibility for loan cancellation; and in the event it is necessary to locate the

borrower’s representative or certifying physician. The SSN is used as a loan account number (identifier) in order to accurately record necessary information.

The routine uses of this information include its disclosure to Federal, State or local agencies, to guarantee agencies, to educational and financial institutions

and to agency contractors for the purpose of: verifying the identity of the borrower and the borrower’s physician: determining the borrower’s eligibility for loan

cancellation; investigating possible fraud and verifying compliance with program regulations. Failure to provide the requested information may cause the Department

of Education to deny the borrower’s request for loan cancellation.

This information is necessary to process requests for loan cancellation.

HEAL Form 539 (BACK)