Form PA-1000 PS "Physician's Statement of Permanent and Total Disability" - Pennsylvania

What Is Form PA-1000 PS?

This is a legal form that was released by the Pennsylvania Department of Revenue - a government authority operating within Pennsylvania. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Pennsylvania Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form PA-1000 PS by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Revenue.

ADVERTISEMENT
ADVERTISEMENT

Download Form PA-1000 PS "Physician's Statement of Permanent and Total Disability" - Pennsylvania

825 times
Rate (4.7 / 5) 58 votes
1805310057
PHYSICIAN’S STATEMENT
Physician’s Statement of
Permanent and Total Disability
PA-1000 PS 06-18
(FI)
2018
PA Department of Revenue
OFFICIAL USE ONLY
START
Name as shown on PA-1000
Social Security Number
Instructions
A claimant not covered under the federal Social Security Act or the federal Railroad Retirement Act who is unable
to submit proof of permanent and total disability may submit this Physician’s Statement. The physician must deter-
mine the claimant’s status using the same standards used for determining permanent and total disability
under the federal Social Security Act or the federal Railroad Retirement Act. CAUTION: If the claimant applied
for Social Security disability benefits and the Social Security Administration did not rule in the claimant’s favor,
the claimant is not eligible for a Property Tax or Rent Rebate.
Confidentiality Statement. All information on this Physician’s Statement and claim form is confidential. The
department shall only use this information for the purposes of determining the claimant’s eligibility for a Property
Tax or Rent Rebate.
CERTIFICATION
I certify the claimant named above is my patient and is permanently and totally disabled under the standards that
the federal Social Security Act or the federal Railroad Retirement Act requires for determining permanent and total
disability. Upon request from the PA Department of Revenue, I will provide the medical reports or records indicat-
ing diagnosis and prognosis of the claimant’s condition, including signs, symptoms and laboratory findings, if
applicable or appropriate.
Please sign after printing.
MM/DD/YY
Physician Signature
Date
Description of Claimant’s Permanent and Total Disability. Briefly describe the reason(s) the above-named
claimant is totally and permanently disabled.
Physician Identification Information. Please print.
Name
National Provider Identifier
Business name, if applicable
Address
City
State
ZIP Code
Office telephone number
Office email address
1805310057
1805310057
TOP OF PAGE
PRINT
Reset Entire Form
1805310057
PHYSICIAN’S STATEMENT
Physician’s Statement of
Permanent and Total Disability
PA-1000 PS 06-18
(FI)
2018
PA Department of Revenue
OFFICIAL USE ONLY
START
Name as shown on PA-1000
Social Security Number
Instructions
A claimant not covered under the federal Social Security Act or the federal Railroad Retirement Act who is unable
to submit proof of permanent and total disability may submit this Physician’s Statement. The physician must deter-
mine the claimant’s status using the same standards used for determining permanent and total disability
under the federal Social Security Act or the federal Railroad Retirement Act. CAUTION: If the claimant applied
for Social Security disability benefits and the Social Security Administration did not rule in the claimant’s favor,
the claimant is not eligible for a Property Tax or Rent Rebate.
Confidentiality Statement. All information on this Physician’s Statement and claim form is confidential. The
department shall only use this information for the purposes of determining the claimant’s eligibility for a Property
Tax or Rent Rebate.
CERTIFICATION
I certify the claimant named above is my patient and is permanently and totally disabled under the standards that
the federal Social Security Act or the federal Railroad Retirement Act requires for determining permanent and total
disability. Upon request from the PA Department of Revenue, I will provide the medical reports or records indicat-
ing diagnosis and prognosis of the claimant’s condition, including signs, symptoms and laboratory findings, if
applicable or appropriate.
Please sign after printing.
MM/DD/YY
Physician Signature
Date
Description of Claimant’s Permanent and Total Disability. Briefly describe the reason(s) the above-named
claimant is totally and permanently disabled.
Physician Identification Information. Please print.
Name
National Provider Identifier
Business name, if applicable
Address
City
State
ZIP Code
Office telephone number
Office email address
1805310057
1805310057
TOP OF PAGE
PRINT
Reset Entire Form