Louisiana teachers applying for disability retirement through TRSL give this report to their physician after completing the applicant sections. The physician documents history, review of systems, exam, diagnosis with DSM or ICD codes, treatment, prognosis and functional abilities, with objective findings strong enough to show the member cannot keep performing current job duties. TRSL also uses it for a disabled child's survivor benefit.
The applicant completes Section 1, applicant information, and signs Section 2, the authorization to release medical records. The physician or health care provider completes and signs Section 3, the physician's report of disabling condition.
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Physician Report of Disabling Condition
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Yes. Form 12C says a physician who chooses to dictate the medical report should include the information outlined on the form, from history of present conditions through diagnosis, treatment and prognosis. Copies of all medical records must still accompany the report, and the physician signs Section 3.
The form asks for objective clinical findings and laboratory evidence of sufficient magnitude to justify the patient's claim that they can no longer perform current job-related duties. Diagnosis entries should include the results of the tests that document each diagnosis.
Yes. The same physician report supports a survivor benefit claim for a member's disabled child, filed with Form 12PDMC, the Statement of Child's Permanent Disabling Condition. In that case the applicant section identifies both the applicant and the TRSL member.