Requesting Short-Term Benefits Through The Disability Income Plan Of North Carolina
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4Requesting Short-Term Benefits Through the
Disability Income Plan of North Carolina
Please print or type in black ink.
Section A.
Tell us about yourself.
FIRST NAME
MI LAST NAME
SSN
MAILING ADDRESS
MEMBER ID
TELEPHONE NO.
STATE
DATE OF BIRTH
ZIP CODE
CITY
Please read and/or discuss with your employer Guides A through G before proceeding.
Section B.
Please authorize benefits and disclosure of medical records with your signature.
I certify that my illness did not result from active participation in a riot or committing or attempting to commit a terrorist act, felony,
or intentional, self-inflicted injury.
I hereby authorize any physician, hospital, employer, agency, or other organization to disclose and release to my employer or the
Retirement Systems Division any medical records or other information about my disability. I understand that a copy of this
authorization will be considered to be as valid as the original. I further understand this information is to be furnished at no cost to
my employer or to the Retirement Systems Division.
I certify that I have read optional pages 1 and 2 and that, to the best of my knowledge, I am eligible to request benefits through the
Disability Income Plan of North Carolina. Further, I understand that I cannot withdraw my contributions from the Retirement
System while receiving benefits under this Plan, and I understand that approval for short-term or preliminary long-term benefits is
no indication of my eligibility for further benefits from the Plan.
Signature _______________________________________________________________________ Date___________________
Submit this form to your employer, who should complete Sections C though G
You may submit these forms independently of your employer, but doing so may cause a delay in the processing of your
benefit and health insurance (if applicable), because the Retirement Systems Division will prepare your employer to
administer the benefit as necessary. If you decide to submit these forms independently, please check the box at right.
Section C.
Employer, please identify the applicable benefit track.
Based on your discussion with the employee (see Guide D), which authority will determine whether or not the employee's illness
meets state law requirements for benefits from the Disability Income Plan of North Carolina?
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(a) The employer will make the determination. This form is being submitted to the Retirement Systems Division as part of a
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report and application for reimbursement of short-term benefits (see Section H) and/or as part of an application for extended
short-term or long-term benefits).
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(b) The Medical Board will make the determination for a short-term benefit per the request of the employer or the
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employee. This form is being submitted to the Retirement Systems Division along with other documents (see Section H).
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(c) The Medical Board will make the determination for a short-term benefit per the request of the employer or the employee
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and will make a preliminary finding to waive monthly medical reports. This form is being submitted to the Retirement Systems
Division along with a Form 7A and a job description (see Section H).
Section D.
Employer, please review the employee's benefits through other agencies.
Is the employee currently receiving or eligible to apply for or receive Workers' Compensation benefits?
Yes
No
If YES, please attach a copy of the Form 60 or Form 21 from the North Carolina Industrial Commission.
Is the employee currently receiving or eligible to apply for or receive Veterans Affairs benefits?
Yes
No
If YES, please attach a copy of the awards notice.
Please continue to the next page.
REV 20071009
701
Page 1 of 2
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