The Employees' Retirement System of Georgia requires Part IV of its Disability Retirement Application from each medical provider the member lists. The treating physician evaluates, against the attached job description, whether the member is medically or physically incapable of performing the duties and whether that incapacity is likely permanent. The ERSGA Medical Board uses it to decide eligibility.
The member completes Sections 1 to 3: general information, physician details and a release of all medical records, including psychiatric records. The physician, hospital or clinic completes Section 4, Employee Disability Information, and signs Section 5, the certification.
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Disability Retirement Application Part IV: Employee's Request for Disability Information From Physician/Physician's Report
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Yes. The application checklist requires a separate physician's report from each medical provider the member lists in Part II. The member gives every provider a copy of Part IV with Sections 1 to 3 completed and the current job description from Part V attached.
All records that document and support the diagnosis for the past 18 months: history, copies of tests, office notes, typed imaging reports, hospital admissions, operative notes, discharge summaries and referral reports. Section 4 also asks for onset date, findings, treatment and compliance, pending tests or surgery, and referrals.
The member. The Part IV instructions ask the physician to bill the patient for any charges relating to the request, and tell the member they are responsible for charges relating to the records authorization. ERSGA pays only if its Medical Board orders an independent medical exam.