Downloading a Form to Your Computer

  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.

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Effective Date: 
3/2019

Documents

 

Instructions

Updated: 1/2004

 

Purpose

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

Procedure

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.

Transmittal

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.