Examining Physician'S Statement For Application For Disability Benefits Form printable pdf download

33 Plaza La Prensa, Santa Fe, New Mexico 87507

(505) 476-9401 fax

(505) 476-9300 voice

(800) 342-3422 Toll-Free

EXAMINING PHYSICIAN’S STATEMENT FOR APPLICATION FOR

DISABILITY BENEFITS FORM

Instructions: Please print or type in dark ink. The original of this form must be completed in its ENTIRETY and

returned to PERA for processing. ENTERING “SEE ATTACHED” IS NOT SUFFICIENT. A brief explanation MUST

be on this form.

Information Needed from the Health Care Provider

The member named below is applying for PERA disability retirement. To be considered, PERA must receive a complete

medical and/or psychological history and report on him/her. In addition, please send a copy of all medical or

psychological records relating to examinations or treatments relating to this applicant’s claim for disability retirement,

especially as they relate to the claimant’s ability to work.

If available, include office notes, laboratory test results, hospital history, physical history, discharge summary, ability to

work and X- ray, pathology and consultation reports. Please include medical information that is current within 3 months

from date of application. The member is responsible for providing all medical documentation and current doctor’s

narratives to PERA.

Please type or print so that others can read this information. Attach additional sheet(s) if necessary.

1. Name of Claimant

2. Social Security Number

▬

3. Height _________________

Weight __________________

4. Date present illness, injury or condition began

5. A brief explanation of previous relevant history of illness, injury or condition ________________________________

6. A brief explanation of contributing causes to present illness, injury or condition, if any ________________________

7. Do you consider this disability to have occurred as the result of causes arising, solely and exclusively out

of and in the course of the claimant’s employment?

Yes

If yes, A brief explanation of why? _______________________________________________________________

8. A brief explanation of symptoms _________________________________________________________________

9. A brief explanation of diagnosis __________________________________________________________________

10. A brief explanation of objective findings (attach copies of relevant test results) ___________________________

September 2015

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Examining Physician'S Statement For Application For Disability Benefits Form