Maine public employees applying for disability retirement can have their healthcare provider record an assessment on this two-page MainePERS form. Maine law lets providers document a patient's ability to work against the disability retirement standards, and the form walks through diagnoses, diagnostic basis, functional limitations, ability to perform essential job functions with reasonable accommodations, permanence, and a narrative explaining the opinions.
The patient's reviewing healthcare provider completes items 1 through 6 and signs, adding name and specialty or subspecialty. The member handles the application itself, including the DC-0003a addendum and the DC-0603 consent form authorizing release of information.
Download the current version from the source each time; forms change without notice.
Application for Disability Retirement Healthcare Provider Assessment
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MainePERS states it created the form because Maine law allows healthcare providers to record their assessment of a patient's ability to work in light of the disability retirement standards that govern a member's eligibility. It gives the provider a structured way to address those standards point by point.
The patient's name and date of birth, the healthcare provider's name, the date of the most recent examination, and the medical conditions the member applied on. The numbered items then address those conditions, from diagnoses through permanence and a closing narrative.