Every Massachusetts public employee who applies for disability retirement must file a statement from a licensed medical doctor under 840 CMR 10.06(1)(b). The applicant names the treating physician on the application, the retirement board sends this 12-page PERAC form, and the board treats the application as incomplete until the statement comes back. The answers put clinical findings into the legal tests of incapacity, permanence and causation.
The licensed medical doctor treating the applicant for the claimed disability answers the background items and questions (1) through (6) as they apply, then signs the physician's certification under the penalties of perjury. Page 2 carries the applicant's details, the claim type and the retirement board's return address.
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Physician's Statement Pertaining to a Member's Application for Disability Retirement
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It depends on the claim type checked on page 2. Ordinary disability needs question (1) on incapacity and (2) on permanency. Accidental disability adds (3A) on causation, or (3B) when a heart, lung or cancer presumption applies. Violent act injury claims need (1), (2), (3A) and (4) through (6) on the injury, the attack and the weapon.
Dates of injury or exposure, diagnoses, how long the physician has treated the applicant, key tests or imaging, the job title, whether the job duties were reviewed, when the applicant last performed the essential duties, restrictions, whether maximum medical improvement has been reached, and treatments and surgeries with their outcomes.
PERAC directs physicians with questions about the statement or the disability process to the applicant's retirement board, the same board that sends the form and receives it back. Definitions of accidental and ordinary disability, aggravation of a pre-existing condition, risk of re-injury and the permanency standard are printed on the form's last two pages.