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MSRS Medical Statement: Correctional Plan (MN)

Minnesota correctional employees covered by the MSRS Correctional Retirement Plan need two medical statements to apply for a disability benefit. This five-page version records the disabling condition with ICD code, onset, findings, tests, treatment, prognosis and psychiatric and physical capacities, and asks whether the employee is occupationally disabled under the Correctional plan's definition rather than an any-work test.

Who completes it

One statement must be completed by a licensed and practicing physician (MD); the second by another MD, physician assistant, psychologist, nurse practitioner (APRN), chiropractor or podiatrist. The member completes the Application for Disability, and the employer completes the Employer Certification Form.

Submitting and payment

How to submit it
Mail or fax the completed statement to MSRS, where its medical advisors review it with the member's Application for Disability and the Employer Certification.

Good to know

  • The Correctional plan defines disability as a physical or psychological condition lasting at least one year that prevents the member from performing normal job duties.
  • Duty-related disability requires an injury or disease arising from duties that present inherent danger and are specific to a covered position; any other cause is a regular disability.
  • Item 13 asks whether the patient is occupationally disabled: if yes, give the date the disability began; if no, the date the patient may resume employment.
  • After approval, MSRS may require recertification by a medical professional once a year for five years, then every three years until full retirement age.

Get the official form

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

Medical Statement (Correctional Retirement Plan)

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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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

What is the difference between duty-related and regular disability on the MSRS Correctional form?

Duty-related disability means the injury or disease arose while performing duties that present inherent danger and are specific to a position covered by the plan. Regular disability covers conditions from activity off work, or at work during duties that do not present that inherent danger.

How many medical statements does MSRS need for a Correctional disability claim?

Two. One must be completed by a licensed and practicing physician (MD). The second may come from another MD, a physician assistant, psychologist, nurse practitioner (APRN), chiropractor or podiatrist. A signed, dated narrative that answers every question can replace the form.