Ohio Public Employees Retirement System
277 East Town Street, Columbus, Ohio 43215-4642
1-800-222-PERS (7377)
*DR-APPLREQ*
Disability Benefits Appeal Request Form
You have the right to file an appeal of the OPERS Board of Trustees’ denial or termination of your disability
benefit.
Instructions: Please choose 1, 2 or 3 below and complete the form accordingly.
1) File a request to appeal, seek an extension at a later date (if needed):
If you wish to file a request to appeal please complete Sections 1, 2 and 4 of this form. OPERS must
receive this form within 30 days from the date of the letter notifying you of the Board’s decision denying
or terminating your disability benefits. You will have 45 days from the date OPERS receives this form
to submit your completed Report of Physician form (DR-APS) and any additional objective medical
evidence you deem necessary.
2) File a request to appeal and request an extension to submit your additional objective medical evidence:
If you wish to file a request to appeal and request an extension please complete all sections of this form
and return it to OPERS within 30 days from the date of the letter notifying you of the Board’s decision.
You will have 90 days from the date OPERS receives this form to submit your completed Report of
Physician form (DR-APS) and any additional objective medical evidence you deem necessary.
3) If you previously filed a request to appeal and now need to request an extension:
Please complete Sections 1, 3 and 4 and return this form to OPERS no later than 45 days from the date
OPERS received your initial request to appeal. Submitting this request for an extension will allow you
an additional 45 days to provide your completed Report of Physician form (DR-APS) and any additional
objective medical evidence you deem necessary.
Important: Please note, Managed Medical Review Organization (MMro) may be contacting you regarding
your appeal.
Section 1 - Member’s Personal Information
Gender
Date Of Birth
Social Security Number
Male
Female
Month
Day
Year
First Name
MI
Last Name
Suffix
Street or Mailing Address
Apt. Number
State
ZIP Code
City
-
Home Phone Number
Work Phone Number
Cell Phone Number
Preferred Telephone Number for Contact: Home
Work
Cell
Preferred Time to Call: Morning
Afternoon
Evening
E-mail Address
DR-APPLREQ (Revised 04/14)
OPERS/MMro
1
1
2
