Box 44516 Baton Rouge, Louisiana 70804-4516-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1 by selecting the reason for completion: Disability Retirement, Annual Re-Examination, or Surviving Child with Disability. Simply click on the appropriate checkbox.
3. In Section 2, fill in the Patient Information. Enter the last name, first name, middle initial, suffix, social security number, address, telephone numbers (home and cell), city, state, zip code, and email address.
4. Authorize the release of medical records by signing and dating the form in Section 2.
5. Proceed to Section 3 where the physician must provide a report. Include details such as dates of care, examination results, medical history, and any relevant clinical findings.
6. Complete Section 4 by marking all applicable boxes regarding the patient's disability status and ensure that the physician signs and dates this section.

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