Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

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Effective Date: 




Updated: 1/2004



To verify permanent disability as defined by the Social Security Administration if the disability is not obvious to the worker.


When to Prepare

Workers give the form to the client to take to his medical provider if needed to verify that a claimed disability is considered permanent by the Social Security Administration.

Number of Copies

The worker gives the client one copy.


The client gives the form to his physician, physician's assistant (under physican's orders), advanced practice nurse, or a licensed osteopath. The medical provider sends the completed form to the certification office where it is filed in the client's case record.

Form Retention

The certification office keeps the case record copy for three years from the month the form is completed by the physician.

Detailed Instructions

Certifying Office — Enter the name of the client who claims disability, his address, the case name and number, and office address and phone number. Sign and date the form.

Physician — The physician's entries are self-explanatory.

The client does not complete any part of this form.