Illinois Municipal Retirement Fund members who file for temporary or total and permanent disability benefits need a physician to certify the claim on this statement. It reaches the clinician through the patient, who generates it in IMRF's Member Access, and it gives IMRF the diagnosis, treatment dates, services rendered and dates of disability it needs to decide the claim.
The doctor who first certified that the member could not work completes it, and so does each other licensed and practicing physician certifying the disability. The member files the Member's Application for Disability Benefits online, and the employer's IMRF Authorized Agent completes the Employer Statement in Employer Access.
Download the current version from the source each time; forms change without notice.
Physician's Statement—Disability Claim
Illinois Municipal Retirement Fund (IMRF) takes this form through its online services or your EMR, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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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There is no public blank copy. IMRF forms are bar-coded and generated for the individual member, who prints the statement from Member Access or asks IMRF to mail it. The member then gives it to each certifying physician, who completes it and sends it to IMRF with the supporting medical records.
IMRF requires the statement and medical records from the doctor who originally certified that the member was unable to work, and from each licensed and practicing physician who is certifying the disability. A missing statement from any of those physicians can delay the decision.
IMRF says the diagnosis, treatment dates, services rendered and dates of disability are required to process the claim. Copies of medical records from the date of disability should accompany the statement, and IMRF may contact the provider directly if it needs more detail.