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MSRS Medical Statement: General Employees Plan (MN)

Minnesota state employees in the MSRS General Employees Retirement Plan who apply for a disability benefit need two medical statements, and this five-page form is the one MSRS provides. It records the disabling condition with ICD code, onset, findings, tests, treatment, prognosis and work capacities, and asks whether the patient is totally and permanently disabled under state law.

Who completes it

One statement must come from a licensed and practicing physician (MD); the second may come from another MD, a 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

  • GERP defines total and permanent disability as inability to engage in any substantial gainful activity due to an impairment that has lasted or is expected to last at least one year.
  • A signed, dated narrative is accepted instead of the form if it answers every question and states opinions clearly; supporting clinical findings and test results should be attached.
  • Physical capacity is rated against the Department of Labor's Dictionary of Occupational Titles categories, from sedentary to very heavy, with occasional, frequent and constant limits.
  • 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 (General Employees 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

Who can sign the MSRS Medical Statement?

A practicing physician, physician assistant, psychologist, nurse practitioner (APRN), chiropractor or podiatrist can sign it. However, of the two statements MSRS requires, at least one must be completed by a licensed and practicing physician (MD).

Can a narrative letter replace the MSRS Medical Statement?

Yes. MSRS accepts a narrative statement in lieu of the form if all questions are addressed, opinions are clearly stated, and it is signed and dated by an eligible practitioner. Supporting clinical findings and laboratory and diagnostic tests should still be included.

Who decides an MSRS General Employees disability claim?

MSRS medical advisors review all of the medical information submitted, and the Executive Director of the Minnesota State Retirement System approves or denies the disability benefit based on their recommendation.