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

Examining Physician'S Statement For Application For Disability Benefits Form Page 3

Page 3 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”.

18. What permanent restrictions, if any, do you believe claimant will have?

19. Will the claimant likely be capable of returning to his or her regular occupation? Yes

If Yes, approximate date

Explain:

20. Are you able to give this claimant a social security impairment rating?

Yes

as to regular occupation

as to any gainful employment

If not, a brief explanation of why not? _____________________________________________________________

(Print or type)

21. Have you evaluated claimant’s functional capacities?

If so, please attach report.

This form must be signed by a medical doctor (M.D.),

psychologist (Ph.D.) or psychiatrist (M.D.) or doctor of

osteopathic medicine (D.O.) per PERA rule 2.80.1000.30 A.(2)

Date

Signature

Print Name

Address

Phone

Fax

September 2015

Page 3 Examining Physician’s Statement

Examining Physician'S Statement For Application For Disability Benefits Form Page 3