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MSRS Medical Statement: State Patrol Plan (MN)

Minnesota State Patrol troopers covered by the MSRS State Patrol Retirement Plan need two medical statements when they apply for a disability benefit. This five-page version captures the disabling condition, ICD code, onset, clinical findings, treatment history, prognosis and work capacities, and asks whether the member is occupationally disabled from normal job duties under the State Patrol plan's definition.

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

  • The State Patrol plan defines disability as a physical or psychological condition lasting at least one year that prevents the member from performing normal job duties.
  • A duty-related disability must arise from duties that present inherent danger and are specific to a State Patrol plan position; other causes count as regular disability.
  • Psychiatric capabilities are rated none, slight, moderate or marked across eight work abilities, and the provider describes work environments that would suit a return to work.
  • After approval, MSRS may require recertification once a year for the first 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 (State Patrol Retirement Plan)

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

What does occupationally disabled mean on the MSRS State Patrol form?

Under the State Patrol plan, disability is a physical or psychological condition lasting at least one year that prevents the member from performing normal job duties. The item 13 opinion is measured against that definition, not the any-substantial-gainful-activity test used for the General Employees plan.

Can a physician assistant or chiropractor complete the State Patrol medical statement?

Yes, for the second statement. MSRS requires two statements: one from a licensed and practicing physician (MD), and a second from another MD, a physician assistant, psychologist, nurse practitioner (APRN), chiropractor or podiatrist.