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LASERS MSD12 Attending Physician's Statement

LASERS uses this statement to review whether a Louisiana state disability retiree's benefits should continue. The attending physician reports diagnosis, subjective symptoms, objective findings, treatment, progress and current functional abilities, then chooses between two opinions: the retiree remains incapacitated and should stay retired, or needs re-evaluation by a LASERS Board Physician because they can return to their former position.

Who completes it

The retiree completes Section 1, member information. The attending physician or designee completes Sections 2 through 7, plus the attached Medical Bills invoice if the practice wants LASERS to pay for the report.

Submitting and payment

How to submit it
Return the completed form to LASERS by mail or fax. Every section should be completed, because an incomplete form delays the patient's benefits.
Who pays
LASERS pays for completing the statement when the physician or designee fills in the attached MEDBILLS invoice for the current office visit and includes a copy of the medical bill issued to the patient.

Good to know

  • LASERS does not use Social Security's disability standard: retirees need only be disabled from their position with the State of Louisiana.
  • Section 7 lets the physician agree that improvement is not expected or medically likely and that no further annual certification of disability is necessary.
  • Section 6 asks about cognitive deficits, expected improvement with an approximate date, and maximum medical improvement, plus hours of sitting, standing and walking in an 8-hour day.
  • Form MSD12 is revision R032023 and pairs with Form 04-03, the Disability Retiree Earned Income Statement; Form 4-01B is the version used at the initial application.

Get the official form

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

Attending Physician's Statement

Official pagePDF

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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

Does LASERS pay doctors to complete Form MSD12?

Yes, if the paperwork is in order. The physician or designee completes the Medical Bills page, itemizing services for the current office visit only, and must include a copy of the medical bill issued to the patient. LASERS then issues a check as requested on the invoice.

How often is the LASERS MSD12 required?

LASERS uses the MSD12 for the annual certification that decides whether disability benefits continue. The physician can end the cycle by agreeing, in Section 7, that improvement is not expected or medically likely and that no further annual certification of disability is necessary.

What if the physician thinks the retiree can return to work?

The physician selects the second Section 7 option: the employee needs to be re-evaluated by a LASERS Board Physician because they can return to work in the position from which they retired. The other option states the retiree remains incapacitated and should remain retired. One of the two must be selected.