"Physician's Report on Disability" - California

Physician's Report on Disability is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

Form Details:

  • Released on June 1, 2017;
  • The latest edition currently provided by the California Public Employees' Retirement System;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download "Physician's Report on Disability" - California

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Physician’s Report on Disability
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Fax: (916) 795-1280
This form must be completed by a physician/medical specialist who specializes in your disabling condition.
The following information is needed in connection with the patient’s application for disability retirement benefits
under the California Public Employees’ Retirement Law. Type or print clearly.
Member Information
Section 1
Please fill out completely and
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
fully describe the nature and
severity of impairment. Also,
Position/Occupational Title
Birth Date (mm/dd/yyyy)
include copies of the patient’s
medical and referenced
For Kaiser Patients, Medical Record Number
diagnostic test reports.
Member History
Section 2
Please provide history of
Date of First Visit (mm/dd/yyyy)
Date of Last Examination (mm/dd/yyyy)
patient’s illness/injury.
Patient and Member are
Date Present Illness/Injury Occurred (mm/dd/yyyy)
Date Member Unable to Perform Job Duties (mm/dd/yyyy)
the same person.
F
F
Origin of Injury:
Work Related
Non-Work Related
Describe How Injury Occurred
Examination Findings
Section 3
Please provide history of
Chief Complaints
patient’s illness/injury.
Subjective Symptoms
Height
Weight
Blood Pressure
Diagnosis
Section 4
Provide dates and findings of
Diagnosis 1
any X-rays, EKGs, laboratory
or diagnostic testing
Objective Examination Findings 1
performed. Use additional
sheets if necessary.
Diagnostic Test – Dates and Findings
Restrictions / Limitations, if so specify.
If there is not enough space
to enter your diagnosis,
attach a separate sheet. Be
Diagnosis 2
sure to use a label, or clearly
Objective Examination Findings 2
write your Social Security
number on each attachment.
Diagnostic Test – Dates and Findings
Restrictions / Limitations, if so specify.
Comments
PERS01M0051DMC (6/17)
Page 1 of 2
Physician’s Report on Disability
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Fax: (916) 795-1280
This form must be completed by a physician/medical specialist who specializes in your disabling condition.
The following information is needed in connection with the patient’s application for disability retirement benefits
under the California Public Employees’ Retirement Law. Type or print clearly.
Member Information
Section 1
Please fill out completely and
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
fully describe the nature and
severity of impairment. Also,
Position/Occupational Title
Birth Date (mm/dd/yyyy)
include copies of the patient’s
medical and referenced
For Kaiser Patients, Medical Record Number
diagnostic test reports.
Member History
Section 2
Please provide history of
Date of First Visit (mm/dd/yyyy)
Date of Last Examination (mm/dd/yyyy)
patient’s illness/injury.
Patient and Member are
Date Present Illness/Injury Occurred (mm/dd/yyyy)
Date Member Unable to Perform Job Duties (mm/dd/yyyy)
the same person.
F
F
Origin of Injury:
Work Related
Non-Work Related
Describe How Injury Occurred
Examination Findings
Section 3
Please provide history of
Chief Complaints
patient’s illness/injury.
Subjective Symptoms
Height
Weight
Blood Pressure
Diagnosis
Section 4
Provide dates and findings of
Diagnosis 1
any X-rays, EKGs, laboratory
or diagnostic testing
Objective Examination Findings 1
performed. Use additional
sheets if necessary.
Diagnostic Test – Dates and Findings
Restrictions / Limitations, if so specify.
If there is not enough space
to enter your diagnosis,
attach a separate sheet. Be
Diagnosis 2
sure to use a label, or clearly
Objective Examination Findings 2
write your Social Security
number on each attachment.
Diagnostic Test – Dates and Findings
Restrictions / Limitations, if so specify.
Comments
PERS01M0051DMC (6/17)
Page 1 of 2
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Member Incapacity
Section 5
To qualify for a disability retirement, the CalPERS member must be substantially incapacitated from the
Review the attached duty
performance of the usual duties of his/her position with the current employer. This “substantial incapacity”
statement and physical
must be due to a medical condition of permanent or extended duration that is expected to last at least
requirements of the
12 consecutive months or will result in death. Disability is not necessarily an inability to perform fully every
member’s position prior to
function of a given position. Rather, the courts have concluded that the test is whether the member has a
answering these questions.
substantial inability to perform the usual and customary duties of the position. Prophylactic restrictions are
not a basis for a disability retirement.
1. Is the member currently, substantially incapacitated from performance of the usual duties of the position
F
F
for their current employer?
Yes
No
If yes, you must describe specific job duties/work activities that the member is unable to perform due
to incapacity. Refer to member’s job duty statement and Physical Requirements of Position/Occupational
Title form.
F
F
2. Will the incapacity be permanent?
Yes
No
F
F
If not, will the incapacity last longer than 12 months?
Yes
No
F
F
3. Was the job duty statement/job description reviewed to make your medical opinion?
Yes
No
4. Was the Physical Requirements of Position/Occupational Title form reviewed to make your
F
F
medical opinion?
Yes
No
F
F
5. Was information reviewed that the member provided?
Yes
No
If so, please attach the information provided by the member.
Physician’s Signature
Section 6
F
F
CalPERS has my permission to release a photocopy of report to member, upon written request.
Yes
No
Mail completed report
directly to CalPERS.
Do not give to member.
Print Physician Name
Phone Number
Fax Number
All questions on this
Address
form must be answered
or application will
City
State
ZIP
be incomplete, which will
delay processing.
Signature of Physician/Title
Medical Specialty
Date (mm/dd/yyyy)
Mail to:
CalPERS Benefit Services Division
P.O. Box 2796, Sacramento, California 95812-2796
PERS01M0051DMC (6/17)
Page 2 of 2
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1.
Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
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