Examining Physician'S Statement For Application For Disability Benefits Form (Page 2 of 3) in pdf

Page 2 of 3

Name of Claimant

Social Security Number

This page must be completed in its ENTIRETY and returned to PERA for processing. Do not use “See Attached”.

11. A brief explanation of treatment plan and medications ________________________________________________

__________________________________________________________________________________________

12. Describe the claimant’s functional limitations (i.e. mobility, dexterity, attitude, etc as to employment and/or activities

or daily living.)_______________________________________________________________________________

__________________________________________________________________________________________

13. Please attach any applicable reports referenced in #12 above. (i.e. functional capacity evaluation, PT notes, etc.)

___________________________________________________________________________________________

14. A brief explanation of expected duration of restrictions ________________________________________________

15. Type of work claimant is presently capable of performing

No Work.

Sedentary Work. May include lifting 10lbs. And occasionally lifting

or carrying such articles as dockets, ledgers and small tools. Job is primarily done sitting, and only

occasional walking and standing are required.

Light work. May include lifting 20lbs. maximum, with frequent lifting

and/or carrying objects weighing up to 10lbs. Job requires walking

or standing to a significant degree, or involves sitting most of the

time with a degree of pushing or pulling of arm and leg controls.

Medium work. May include lifting 50lbs. maximum with frequent

lifting and/or carrying objects weighing up to 25 lbs.

Heavy work. May include lifting 100lbs. maximum with frequent

lifting and/or carrying objects weighing up to 50 lbs.

Very heavy work. Lifting object in excess of 100lbs. with frequent

lifting and/or carrying objects weighing 50 lbs. or more.

Other (Describe)

16. Has the claimant reached maximum medical improvement?

When do you estimate the claimant will

reach maximum medical improvement?

17. If claimant is not presently capable of performing any gainful employment, will claimant be able to

return to some type of employment? Yes

If yes, approximate date

Explain

September 2015

Page 2 Examining Physician’s Statement

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