Rehabilitation counselors request this report from a treating physician, clinic or hospital to help determine a consumer's eligibility for services and plan rehabilitation when cancer is the reported disability. It covers the diagnosis and primary site, metastasis, treatment and medications, current findings, prognosis, employment potential, and functional and extent-of-disease classifications.
The treating physician, clinic or hospital completes the report and the examining physician signs with the date of examination. The counselor fills in the return information, consumer data, reported disability and reason for referral.
Download the current version from the source each time; forms change without notice.
Cancer Disability Medical Report
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.
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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A rehabilitation counselor asks the treating physician, clinic or hospital to complete it. The information is used to help determine eligibility for services and a plan for rehabilitation, and the completed original is kept in the consumer's case file.
Under Employment Potential, whether the person can return to their former occupation, and any limitations such as number of hours or work environment. The report also asks about prostheses or devices needed and plans for medical follow-up.
The HHS forms site notes that some forms cannot be viewed in a web browser's PDF viewer and must be opened in the Adobe Reader application. Form 3112 is one of these dynamic PDF forms, so download it and open it in Adobe Reader to fill it.