Imrf disability form 5 42a 2026

1. Click ‘Get Form’ to open the IMRF Disability Form 5.42a in the editor.
2. Begin by filling in the patient’s last name, first name, middle initial, and social security number. Ensure all mandatory fields are completed using black ink.
3. Provide the patient's mailing address, including city, state, and ZIP code. Include their phone number and occupation.
4. In the mandatory information section (highlighted in red), enter the diagnosis and any concurrent conditions along with the corresponding ICD 9 codes.
5. Attach office visit notes or medical records as required. Specify treatments or services provided, including dates and descriptions of surgical or medical services rendered.
6. Indicate whether the condition is due to an injury or sickness related to employment and if it was caused by an accident. Provide details on any previous similar conditions.
7. Complete the sections regarding the patient's ability to return to work, including any restrictions or limitations.
8. Finally, ensure that a licensed physician signs the form. The signature is mandatory for processing.

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