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LASERS Form 4-01B: Attending Physician's Statement

Louisiana state employees applying for disability retirement through LASERS ask their attending physician to complete Form 4-01B, the last part of the 04-01 Disability Retirement Application packet. It gives ICD-10 diagnoses, symptoms, treatment, progress and functional limits so LASERS can decide whether the member is disabled from their state position, which is the LASERS standard.

Who completes it

The attending physician or the physician's designee completes Form 4-01B. The member completes Form 4-01, the Disability Retirement Application, and the immediate supervisor and agency complete Form 4-01A, the Disability Report.

Submitting and payment

How to submit it
Form 4-01B is submitted to LASERS by mail or fax with all medical records, treatment notes, X-rays and test results attached, since missing records can delay the patient's case.

Good to know

  • Section 7 has two required yes/no opinions: whether the employee is totally incapacitated from future performance of normal job duties, and whether the employee should be retired.
  • Section 6 asks for sitting, standing and walking hours in an 8-hour day, lifting ranges, postural activities, driving and, if applicable, American Heart Association cardiac functional class.
  • LASERS treats an application as valid once Forms 4-01 and 4-01A are complete, and it sends cases to medical review even when records have not arrived.
  • Hazardous duty, corrections, wildlife and harbor police members injured by an intentional act of violence also file Form 4-01C. Form 4-01B is revision R072021.

Get the official form

Download the current version from the source each time; forms change without notice.

Attending Physician's Statement for Disability Retirement

Official pagePDF

How this list is checked

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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Frequently asked questions

Who can complete LASERS Form 4-01B?

The member's attending physician or the physician's designee. The report should include enough detail on history, physical and diagnostic findings, clinical course and therapy for LASERS to determine disability, with medical records, treatment notes, X-rays and test results attached.

Does LASERS use the Social Security disability standard?

No. LASERS bases disability retirement on whether the member is disabled from their position with the State of Louisiana, not on the Social Security test. The physician's opinions in Section 7 address incapacity for the member's normal job duties and whether the employee should be retired.

What diagnosis codes does Form 4-01B require?

Section 3 asks for the primary diagnosis and secondary diagnoses as ICD-10 codes with their code descriptions, followed by detailed subjective symptoms. Extra pages can be attached if they are labeled 'Subjective Symptoms' with the patient's name and Social Security number at the top.