When a SNAP applicant's claimed disability is not obvious to the eligibility worker, Texas HHSC uses this one-page statement to verify whether it is permanent as defined by the Social Security Administration. The provider checks any of 12 listed conditions that apply, or marks that the person has none of them, and signs.
A physician, physician assistant working under physician's orders, advanced practice nurse or licensed osteopath checks the applicable boxes and signs with date, address and phone. The certifying office completes the applicant and case details and signs; the client completes no part.
Download the current version from the source each time; forms change without notice.
Physician's Statement of Permanent Disability
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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The form states that the applicant is responsible for any charges for completing it. HHSC gives the form to the client, who takes it to their provider; there is no state reimbursement noted on the form or its instructions.
According to the HHSC instructions, a physician, a physician assistant working under a physician's orders, an advanced practice nurse, or a licensed osteopath. The provider checks the applicable conditions, then signs, dates and adds their address and phone.
The last option on the form is 'NO', meaning the person does not have any of the listed conditions considered permanently disabling. The form has no free-text field for other diagnoses, so only the 12 listed conditions count.