Florida Retirement System members applying for regular or in-line-of-duty disability retirement need this two-page report from Florida-licensed physicians who have treated them for the disabling condition. The physician reports the diagnosis, prognosis and maximum medical improvement, the level of functional limitation and, for duty-related claims, how the disability relates to an on-the-job injury. State law requires reports from two different physicians, so the disability packet includes two copies.
The member signs the authorization for release of medical information on page 1. Each treating Florida-licensed physician completes the Physician's Statement license block on page 1 and items 1 to 4 on page 2, then signs; the employer reports separately on Form FR-13a, Statement of Disability by Employer.
The top of page 1 asks which type of disability retirement the report supports and prints the statutory definitions: regular disability under section 121.091(4)(b), and in-line-of-duty disability under section 121.021(13), an injury or illness arising out of and in the actual performance of duty. The box checked here decides whether item 4 on page 2, the in-line-of-duty questions, must be completed.
The member signs and dates this release, authorizing the physician to give the Florida Retirement System any information recorded on the examination report and any other pertinent facts and documents about the condition. Have the member sign before the physician releases the completed report and any attached records to the Division of Retirement.
Enter the physician's license number issued by the Florida Board of Medical Examiners, printed name, specialty, address, phone and fax, plus the applicant's name, Social Security number, position title and employer. The statement reminds the physician that the patient pays for completion and that office notes may be added if pertinent, but cannot be submitted in lieu of a properly completed page 2.
Give the date the physician first treated the patient and the date of the most recent examination, then name the primary disabling condition and any secondary conditions. Item 1e asks what restrictions the physician has placed on the patient's activities, so list the specific restrictions rather than leaving the reviewer to infer them from the diagnosis.
Answer yes or no to whether the condition has stabilized and whether the patient has reached maximum medical improvement, and give the date of maximum medical improvement if so. State whether the patient is a candidate for vocational rehabilitation and add comments. These answers speak to the permanence part of the total and permanent disability standard.
Check the one level that fits: no limitation and may return to work; slight limitation, capable of light work; moderate limitation, capable of sedentary work; unable to do present work but capable of another line of work; temporary limitation, temporarily incapable of any work; or a limitation that permanently prevents the member, by a medically determinable physical or mental impairment, from rendering useful and efficient service as an officer or employee.
Complete this item only when in-line-of-duty disability was checked on page 1 and the injury arose out of the performance of duty, and answer all four questions: whether the primary disability is due to an on-the-job injury or illness, the date of injury, how the physician relates the disability to that injury, and whether any other cause contributes, with an explanation.
Use Additional Comments for anything the items above do not capture, then sign, print the physician's name and date the report. Page 2 repeats the applicant's name and Social Security number at the bottom so the clinical page stays matched to the right member if the pages are separated.
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Physician's Report
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Sources for this guide
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Yes. Section 121.091(4), Florida Statutes, requires two different Florida-licensed physicians who have treated the member for the disabling condition. The license number issued by the Florida Board of Medical Examiners goes in the Physician's Statement block on page 1, and the clinical answers on page 2 carry the physician's signature.
The member does. The form states that the patient is responsible for its completion without expense to the State of Florida, so any charge from the physician's office for completing the report is a matter between the office and the member, not the Division of Retirement.
No. The physician may attach office notes and other information when they help explain the member's condition, but the form states that office notes cannot be submitted in lieu of properly completing page 2, where the physician answers the diagnosis, prognosis, impairment and in-line-of-duty items and signs.
Under section 121.091(4)(b), a member is totally and permanently disabled if prevented, by a medically determinable physical or mental impairment, from rendering useful and efficient service as an officer or employee. Item 3 on page 2 includes this as its most severe level, alongside lesser and temporary limitations the physician can check instead.