New Jersey public employees applying for ordinary or accidental disability retirement through the Division of Pensions and Benefits support their application with this two-page report from a personal or treating physician. It covers treatment history, the last physical exam, findings, diagnostic data, diagnosis, and whether the member is totally and permanently disabled from assigned duties, including as a direct result of a work accident.
The member completes Part One with name, date of birth, member number and job title before presenting the form. The treating physician completes Part Two, items 6 through 15, and signs with degree, specialty and New Jersey license number.
Download the current version from the source each time; forms change without notice.
Medical Examination by Personal or Treating Physician
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Office notes may be attached for additional documentation, but each question must still be answered on the form. An incomplete form is returned to the member and delays the disability retirement application, and altered forms are not accepted.
No. Police and Firemen's Retirement System members use BD-1177, the PFRSNJ version of the treating physician form. BD-0021 serves PERS, TPAF, SPRS and the other systems administered by the Division of Pensions and Benefits.
Yes. Besides the treating physician's report and the medical records, disability applicants are examined by physicians selected by the retirement system, so BD-0021 is one part of the medical evidence in the case.