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- Click ‘Get Form’ to open the DR-416 in our editor.
- Begin by entering the Physician’s Name in the designated field. Ensure that you print clearly for legibility.
- Next, input the Patient’s Name and Social Security Number. Remember, the Social Security Number is mandatory as per Florida Statutes.
- Indicate the date of total and permanent disability by filling in the appropriate fields. This should reflect the date when the condition was diagnosed.
- Select the applicable condition(s) from the list provided, such as Quadriplegia or Paraplegia, by checking the corresponding box.
- If applicable, check the box indicating if the patient does not require a wheelchair for mobility.
- The physician must then sign and date the form at the bottom. Include your address and Florida Board of Medical Examiners License Number.
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