Section 2 - Appeal Request
Important - Choosing to appeal this decision requires you to submit a Report of Physician form (DR-APS). You must
submit the Report of Physician form (DR-APS) and any additional objective medical evidence to support your claim no
later than 45 days from the date OPERS receives your initial Appeal Request form.
Please mark the following box if applicable:
Appeal Board’s Decision - I am choosing to appeal the retirement board’s decision to deny/terminate my disability benefit. I
will forward my completed Report of Physician form and any additional objective medical evidence to support my claim.
Section 3 - Appeal Extension Request
Important - This extension request must be received within 45 days from the date OPERS receives your initial Appeal
Request form.
Please mark the following box if applicable:
Extension Request - I request an additional 45 days to submit my completed Report of Physician form and any additional
objective medical evidence to support my claim.
Section 4 - Member’s Acknowledgment
HIPAA DISCLOSURE:
I authorize any licensed physician, medical provider, medical facility or provider of health care or similar entity to release
any and all of the following information to OPERS or their third party administrators:
Medical information with respect to any physical or mental condition and/or treatment of me, including confidential
information regarding AIDS/HIV infection, communicable diseases, alcohol and substance abuse, and mental health.
I understand the information obtained will be included as part of the proof of claim and will be used to determine eligibility
for claim benefits, return to employment opportunities, and assessment of ongoing treatment. Any information obtained will
not be released to any person or organization except OPERS and their third party administrators.
I agree that a photographic copy of this Authorization shall be as valid as the original.
I understand that I may request a copy of this Authorization. This Authorization shall become effective on the date appearing
next to my signature below.
I understand I have the right to revoke this Authorization at any time by notifying OPERS.
I understand that revoking this Authorization may impair necessary processing of my OPERS benefits.
I understand and acknowledge that my appeal request will not be reviewed and decided upon by the OPERS Board of
Trustees until the expiration of the time frame allowed for me to submit my completed Report of Physician form and
objective medical evidence supporting my claim.
Month
Day
Year
Member Signature_________________________________________________________________
Do not print or type name
OPERS/MMro
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DR-APPLREQ (Revised 04/14)
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