Teachers' Retirement System of Louisiana disability retirees return this two-page report to show that their disabling condition continues. The retiree fills in their details and forwards it to a physician, who records history, review of systems, social history, vitals, physical and neuropsychiatric exams, diagnosis with supporting test results, treatment, prognosis, and three opinions about returning to full-time work.
The retiree completes Section 1, retiree information, and forwards the form to the physician. The physician completes Section 2, the report of the patient's disabling condition, and a licensed physician signs Section 3.
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Physician Annual Report of Disabling Condition
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It asks three opinions: whether the patient can return now to full-time work without restrictions in the same area of work as before, whether the condition is terminal or recovery highly improbable, and whether the patient will ever be able to return to such work.
Section 3 must be signed by a licensed physician, who also enters their name, license number, area of specialty, date signed and daytime telephone. The retiree completes Section 1 and is responsible for forwarding the form to the physician for Sections 2 and 3.
Yes. Form 12D says that if the medical report will be dictated, it should include the information outlined on the form: history, review of systems, social history, vital signs, physical and neuropsychiatric examination, diagnosis with test results, treatment and response, and prognosis.