Form GEN 023 Physician's Certificate - Alaska

Form GEN023 is a Alaska Department of Administration form also known as the "Physician's Certificate". The latest edition of the form was released in December 1, 2015 and is available for digital filing.

Download a PDF version of the Form GEN023 down below or find it on Alaska Department of Administration Forms website.

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FOR OFFICE USE ONLY
Physician’s Certificate
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
Public Employees’ Retirement System (PERS)
Teachers’ Retirement System (TRS)
Alaska Cost-of-Living Allowance
MEMBER INFORMATION
Name Last
First
M.I.
Telephone Number
Email Address
(
)
Retirement Identification Number (RIN)
Departure Date from Alaska
I certify that I understand that to receive the Alaska Cost of Living Allowance (COLA), I may be absent from the state due to an
illness for a period not to exceed six months from date of departure. I understand that my eligibility for COLA under this provision is
an exception to the requirements under AS 39.35.480 or AS 14.25.142, which prohibit my absence from the state for a continuous
period exceeding 90 days. I am providing certification by a licensed physician that my absence from the state is required due to
illness.
I also certify that my principle domicile remains in Alaska and I intend to return to Alaska after my illness is resolved. I understand
that if I establish a pattern of absence from the State for more than 90 days on a recurring basis I will be asked to provide
information as outlined under 2 AAC 35.240 to confirm my eligibility for this benefit.
In completing this medical certification, I acknowledge that a person who knowingly makes a false statement, or falsifies or permits to
be falsified a record of the retirement system in an attempt to defraud the system is guilty of a class A misdemeanor, which, upon
conviction, is punishable by a fine of not more than $500.00 or imprisonment for not more than twelve months or both.
I also acknowledge that a person who obtains funds and/or benefits by deception may be subject to prosecution for other crimes,
including theft, which may be charged as misdemeanors or felonies with potential fines and penalties including imprisonment. I also
acknowledge that a person who obtains funds and/or benefits from the system unlawfully may also be required to make restitution.
Signature
Date
PHYSICIAN
I certify that I am a physician licensed to practice and I am providing this certification to the Plan Administrator to establish that
my patient, listed above, must seek temporary medical attention outside of Alaska as a result of an illness.
I further certify that the illness will require continuous absence from the State of Alaska for a period of _______________
months. The absence should commence______________________________.
Signature of Certifying Physician
Date
Printed Name of Physician
Telephone Number
(
)
Address Street or P.O. Box
City
State
ZIP+4
GEN023 (Rev. 12/15)
G:\Communications_Only\200 Products\206 Forms, Applications, Info Packets, Benefit Cards\General\gen023
FOR OFFICE USE ONLY
Physician’s Certificate
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
Public Employees’ Retirement System (PERS)
Teachers’ Retirement System (TRS)
Alaska Cost-of-Living Allowance
MEMBER INFORMATION
Name Last
First
M.I.
Telephone Number
Email Address
(
)
Retirement Identification Number (RIN)
Departure Date from Alaska
I certify that I understand that to receive the Alaska Cost of Living Allowance (COLA), I may be absent from the state due to an
illness for a period not to exceed six months from date of departure. I understand that my eligibility for COLA under this provision is
an exception to the requirements under AS 39.35.480 or AS 14.25.142, which prohibit my absence from the state for a continuous
period exceeding 90 days. I am providing certification by a licensed physician that my absence from the state is required due to
illness.
I also certify that my principle domicile remains in Alaska and I intend to return to Alaska after my illness is resolved. I understand
that if I establish a pattern of absence from the State for more than 90 days on a recurring basis I will be asked to provide
information as outlined under 2 AAC 35.240 to confirm my eligibility for this benefit.
In completing this medical certification, I acknowledge that a person who knowingly makes a false statement, or falsifies or permits to
be falsified a record of the retirement system in an attempt to defraud the system is guilty of a class A misdemeanor, which, upon
conviction, is punishable by a fine of not more than $500.00 or imprisonment for not more than twelve months or both.
I also acknowledge that a person who obtains funds and/or benefits by deception may be subject to prosecution for other crimes,
including theft, which may be charged as misdemeanors or felonies with potential fines and penalties including imprisonment. I also
acknowledge that a person who obtains funds and/or benefits from the system unlawfully may also be required to make restitution.
Signature
Date
PHYSICIAN
I certify that I am a physician licensed to practice and I am providing this certification to the Plan Administrator to establish that
my patient, listed above, must seek temporary medical attention outside of Alaska as a result of an illness.
I further certify that the illness will require continuous absence from the State of Alaska for a period of _______________
months. The absence should commence______________________________.
Signature of Certifying Physician
Date
Printed Name of Physician
Telephone Number
(
)
Address Street or P.O. Box
City
State
ZIP+4
GEN023 (Rev. 12/15)
G:\Communications_Only\200 Products\206 Forms, Applications, Info Packets, Benefit Cards\General\gen023

Download Form GEN 023 Physician's Certificate - Alaska

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