Request for medical information for disability income - UCSB Human ... - hr ucsb 2025

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The document is a request form for medical information needed to assess eligibility for disability income under the University of California Retirement Plan (UCRP). It outlines the necessary patient information, instructions for treatment providers to complete the form, and details regarding the patient's medical condition, functional abilities, and prognosis. Additionally, it includes privacy notifications and emphasizes the importance of providing accurate information for benefits administration.

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How to use or fill out Request for medical information for disability income - UCSB Human Resources

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Click ‘Get Form’ to open it in the editor.
Begin with the 'Member Information' section. Fill in the patient's name, birthdate, patient number (if applicable), and social security number accurately.
Review the 'Notice to the Member/Patient' carefully. Ensure you have the Consent for Disclosure form (UCRS 158) ready to accompany this request.
Instruct your treatment provider to complete their section. They will need to provide details about the patient's last visit, current symptoms, and objective findings.
Ensure that all fields regarding physical and mental impairments are filled out by your physician, including prognosis and any restrictions on work capabilities.
Once completed, save your document and send it directly to UC RASC—Disability Unit at the provided address.

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