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.

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