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PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION FIVE MIDDLESEX AVENUE, SUITE 304 SOMERVILLE, MA 02145IntroductionPhysician's Statement Pertaining to a Member's Application for Disability Retirement

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How to fill out treating physicians statement on

01

To fill out the treating physicians statement, follow these steps:

02

Begin by entering the patient's personal information, including their name, date of birth, and contact details.

03

Specify the date of the examination and the medical facility where it took place.

04

Provide a detailed description of the patient's condition, including any symptoms, diagnoses, and previous treatments.

05

Include information about the medications the patient is currently taking, including dosages and frequencies.

06

Describe any limitations or restrictions the patient may have regarding their daily activities, work capabilities, or social interactions.

07

Indicate the expected duration of the treatment and any follow-up appointments or therapies.

08

Finally, the treating physician should sign and date the statement, providing their contact information for further inquiries.

Who needs treating physicians statement on?

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Treating physicians statements are typically required in situations where an individual is making a claim for insurance benefits or disability accommodations.

02

This statement helps verify the individual's medical condition and treatment, providing supporting evidence for their claim.

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Employers, insurance companies, government agencies, or educational institutions may request a treating physicians statement.

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