The physician's reports that state, teacher, municipal and federal retirement systems require when a member applies for disability retirement or must recertify a disability.
When a public employee applies for disability retirement, the pension system asks the treating physician whether the member can still perform the job and whether the condition is permanent. Common examples are the CalPERS Physician's Report on Disability (CalPERS-1204), Florida's FR-13B, New Jersey's BD-0021, the Massachusetts PERAC Physician's Statement, North Carolina's Form 7A and the OPERS Report of Physician (DR-APS) in Ohio. Federal employees use the SF 3112C under CSRS and FERS.
Standards differ: NYSTRS asks about all gainful employment, while CalPERS asks about the member's usual duties. Florida, Minnesota and Wisconsin systems require two physician reports. Several forms go from the physician straight to the system, not the patient, and Texas ERS requires a notarized original. Where a form mentions fees, the member usually pays, though LASERS pays for its MSD12 continuing-benefits statement when a copy of the bill is included. Vero Documents fills these PDFs from the visit note and the chart; you review and sign.
Collects the physician's objective medical documentation (history, findings, diagnosis, prognosis, restrictions relative to the position description) for a federal employee's CSRS/FERS disability retirement application.
Physician certifies that a military retiree's adult child is incapable of self-support (and/or of handling finances) because of a mental or physical incapacity, for Survivor Benefit Plan / RSFPP child annuity.
Physician's general medical exam showing a retiring CSRS employee is in good health, required when electing an insurable-interest survivor annuity.
RI 30-10Determines whether an adult child of a federal annuitant or deceased employee is incapable of self-support because of a disability that began before age 18, for survivor annuity and FEHB family coverage.
Licensed physician certifies that a PERS/TRS retiree must leave Alaska for medical care for a stated number of months, so the retiree keeps the Alaska Cost-of-Living Allowance despite an absence longer than 90 days (up to six months).
Attending physician's objective medical evidence supporting an ASRS member's claim under the ASRS Long Term Disability Income Program.
CalPERS-1204Medical specialist's opinion on whether a CalPERS member is substantially incapacitated from the usual duties of their position, permanently or for at least 12 months, for disability or industrial disability retirement.
Treating physician's statement supporting a LACERA member's application for service-connected or nonservice-connected disability retirement, assessed against the County class specification.
Treating physician or therapist certifies whether a Cash Balance Benefit Program participant's impairment is total and permanent (expected to prevent creditable service for at least one year), its etiology and duration.
FR-13BFlorida-licensed treating physician reports diagnosis, prognosis/MMI, functional capacity and in-line-of-duty causation to establish total and permanent disability for FRS regular or in-line-of-duty disability retirement (Rule 60S-4.007).
Treating physician states whether a TRS Georgia member applying for disability retirement can perform the attached job description, which duties they cannot perform, and the disability diagnosis.
Treating physician evaluates whether the ERS member is medically or physically incapable of performing the attached job description and whether the incapacity is likely permanent, for the ERSGA Medical Board.
Mental health treating source's report on diagnosis, functioning and ability to perform the job for a TRS Georgia disability retirement application.
Requests that each hospital or clinic that treated the member in the past 12 months send history, operative, radiology, lab and discharge records to TRS for a disability retirement decision.
Treating physician evaluates whether a Georgia PSERS member (school bus drivers, food service and other non-certified school staff) is incapable of performing the attached job description and whether the incapacity is likely permanent.
Certifying physician's statement of diagnosis, treatment dates and dates of disability for an IMRF member's temporary or total and permanent disability benefit claim.
Physician's statement supporting a TRF member's application for the classroom disability benefit (teacher unable to perform classroom duties).
Physician's history, exam, diagnosis, functional impact, treatment and conclusion whether a TRS Kentucky member is disabled (12-month job-duty test or total and permanent duty-related test) for disability retirement and disability retiree reviews.
Attending physician gives ICD-10 diagnoses, symptoms, treatment, progress and functional restrictions to support a LASERS member's disability retirement (LASERS standard: disabled from the member's state position).
Physician's report of history, findings, diagnosis and prognosis supporting a TRSL member's disability retirement application (also used for a disabled child's survivor benefit with Form 12PDMC).
Annual physician report confirming that a TRSL disability retiree's disabling condition continues, with objective findings and prognosis.
Form MSD12Attending physician's report used by LASERS to decide whether a disability retiree's benefits continue (diagnosis, findings, progress, functional abilities), with a section to bill LASERS for the report.
Healthcare provider records diagnoses, diagnostic basis, functional limitations, ability to perform essential job functions (with accommodations) and permanence, under Maine law, for a MainePERS disability retirement application.
Opens and documents a disability retirement claim; Section Three is the treating physician's medical report sent to the Agency's Medical Board for ordinary, accidental or special disability (employees, teachers, correctional officers, state police, LEOs, judges, legislators).
Treating physician's statement, required by 840 CMR 10.06(1)(b), on incapacity, permanence and causation (accidental, ordinary, presumption, violent act injury) for a Massachusetts public employee's disability retirement application to one of the 104 local retirement boards.
Certificate completed by the PERAC regional medical panel physicians after examining a disability retirement applicant, answering incapacity, permanence and causation questions (variants for accidental, ordinary, heart, lung, cancer presumptions etc.).
Medical report on the member's condition required (two reports, same condition) for a TRA total and permanent disability benefit.
Medical professional documents the disabling condition (ICD code), onset, findings, treatment, prognosis and psychiatric/physical capabilities, and whether the employee is disabled under the Correctional Retirement Plan definition, for an MSRS disability benefit.
Medical professional documents the disabling condition (ICD code), onset, findings, treatment, prognosis and psychiatric/physical capabilities, and whether the employee is disabled under the General Employees Retirement Plan definition, for an MSRS disability benefit.
Medical professional documents the disabling condition (ICD code), onset, findings, treatment, prognosis and psychiatric/physical capabilities, and whether the employee is disabled under the State Patrol Retirement Plan definition, for an MSRS disability benefit.
Treating physician's statement on diagnosis, restrictions and permanent incapacity for any occupation for a Public Education Employee Retirement System (non-certificated school staff) disability retirement.
Treating physician documents diagnoses, objective findings, lifting/positional restrictions and whether a Public School Retirement System member is incapable of earning a livelihood in any occupation, permanently, for PSRS disability retirement.
Treating physician documents findings, diagnosis, and whether the member is totally and permanently disabled from assigned duties (and whether as a direct result of a work accident) for ordinary or accidental disability retirement (PERS, TPAF, SPRS and other NJDPB systems).
Treating physician documents findings, diagnosis and total and permanent disability (and work-accident causation) for a PFRS member's ordinary or accidental disability retirement.
Pre-enrollment physical examination of a new police officer or firefighter documenting history and exam findings for PFRS membership.
Applicant's physician certifies symptoms, diagnosis, treatment, prognosis and that the member is physically or mentally incapacitated for duty, for the TRS Medical Board's review of an ordinary or accident disability retirement application.
Treating physician certifies diagnosis, cause, objective and subjective evidence, treatment and expected return to full duties for the NYCERS Medical Board's review of a disability retirement application.
RET-54.3Physician states dates of treatment and onset and whether the member is totally and permanently disabled from all gainful employment, with a narrative of history, treatment, diagnosis and prognosis, for NYSTRS disability retirement.
Licensed physician documents diagnoses (ICD-10), onset, treatment, mental assessment and whether the member is temporarily or permanently unable to perform their job, for disability retirement (TSERS, LGERS, CJRS, LRS, Firefighters' & Rescue Squad Workers' Pension Fund) and DIPNC benefits.
Monthly earnings report plus a medical professional's certification that a TSERS/ORP member is continuously disabled and unable to perform their regular job, for short-term benefits under the Disability Income Plan of North Carolina (DIPNC).
DR-APSAttending MD/DO determines whether an OPERS member is permanently disabled (12+ months) from their last public position and documents diagnosis with ICD code, prognosis and body-system findings.
Treating medical specialist's report on whether an STRS Ohio member is disabled from their last position for at least 12 months, for disability allowance or disability retirement.
Attending MD/DO reports ongoing treatment and whether an OPERS disability benefit recipient remains permanently disabled from their last public position.
PSRS-1236Treating physician's report of current disabling symptoms, findings and limitations explaining why a PSERS member cannot perform their job duties, reviewed by PSERS' contracted medical examiners without a personal exam.
Treating physician's history, findings, diagnoses, treatment and opinion on whether a SERS member can perform the duties in their position description, on which SERS' contracted reviewing physician bases a disability retirement recommendation.
Physician's statement supporting a South Carolina public employee's claim under the Basic (self-funded) or Supplemental LTD plan.
Attending physician documents diagnoses and body-system findings, and whether the impairment prevents past work and all other gainful employment, for TCRS ordinary or accidental disability retirement.
Attending physician's statement used by the TRS Medical Board to certify that a member is mentally or physically disabled from further performance of duty and that the disability is probably permanent.
MD/DO documents diagnoses (no ICD codes), history, functional and environmental limits, and whether the condition is likely permanently incapacitating for state employment and other occupations, for ERS occupational or non-occupational disability retirement.
TCDRS-32Attending physician's findings, physical and mental limitations and certification whether a TCDRS member is incapacitated from any gainful occupation, likely permanently (and whether duty-related), for the TCDRS Medical Board.
VRS-6BPhysician or other medical professional describes the functional limitations, diagnoses, treatment and permanence of the condition(s) on which a VRS member's disability retirement application is based, for the VRS Medical Board.
ET-5303Licensed physician certifies that a Wisconsin Retirement System participant meets the statutory definition of disabled for a WRS disability retirement benefit (Wis. Stat. 40.63).
Physician's report establishing a state employee's disability for Income Continuation Insurance benefits under Wis. Stat. 40.61 and 40.62.
Physician recertifies that a WRS disability retirement annuitant remains disabled, based on an examination within the past 12 months.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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A physician or medical specialist who specializes in the member's disabling condition. The CalPERS-1204 asks whether the member is substantially incapacitated from the usual duties of the position, permanently or for at least 12 months, and the physician must review the duty statement. For state and school members, the physician sends the report and records directly to CalPERS, not to the member. Local safety members return it to their employer, which decides.
Yes. Florida law requires FR-13B Physician's Reports from two different Florida-licensed physicians who have treated the member. Each covers diagnosis, prognosis and maximum medical improvement, functional capacity and whether the disability arose in the line of duty. Office notes cannot replace page 2. The form says the patient is responsible for completion without expense to the State of Florida, and it serves both Pension Plan and Investment Plan members.
Yes. On ERS 2.12, the Attending Physician Statement for Disability Retirement Application, the physician's signature must be witnessed by a notary public, and the original is mailed to ERS with the member's application and records; notarized forms may not be faxed. Only an MD or DO may complete it. Diagnoses must be written out, because ICD codes are not accepted, and the patient pays any charges.
The SF 3112C, Physician's Statement in Connection With Disability Retirement under CSRS and FERS. It is part of the SF 3112 packet and asks the treating physician for objective medical documentation: history, findings, diagnosis, prognosis and restrictions measured against the position description, with a narrative and test results attached. The physician returns it to the agency personnel office, or to the applicant if separated more than 31 days.