Texas state employees applying to ERS for occupational or non-occupational disability retirement need a medical doctor to complete this notarized statement, part of the Disability Retirement Packet. It covers diagnoses written out in words, history, findings, six-month progress, activity and environmental limits, and whether the condition is likely to permanently incapacitate the patient for state employment and for other occupations.
Only a Doctor of Medicine or Doctor of Osteopathic Medicine may complete the statement, and the signature must be witnessed by a notary public. The member completes ERS 2.11, and the employing agency completes the ERS 2.221 Departmental Statement.
Download the current version from the source each time; forms change without notice.
Attending Physician Statement for Disability Retirement Application
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.
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Yes. The medical doctor's signature must be witnessed by a notary public, and ERS needs the original notarized form by mail. Notarized forms may not be faxed, and copies of forms are not accepted with the application.
No. Only a Doctor of Medicine or Doctor of Osteopathic Medicine is authorized to complete the Attending Physician Statement for an ERS disability retirement application, and that doctor lists clinic affiliation, primary specialty and medical school graduation date.
No. The form states that ERS does not accept codes. Each diagnosed disease or injury must be written out, along with the date of diagnosis, the cause, and the dates the physician first and last examined the patient for it.