Free 17296.PDF - Indiana

ATTENDING PHYSICIAN'S STATEMENT
State Form 17296 (R2 / 1-02) Approved by the State Board of Accounts 2002

INDIANA STATE TEACHERS'RETIREMENT FUND 150 West Market Street, Suite 300 Indianapolis, Indiana 46204-2809 Telephone (317) 232-3860 / Toll Free: (888) 286-3544 Home Page: www.in.gov/trf
PRIVACY NOTICE

This form must be delivered by the applicant to the attending physician. It must be made in the handwriting of the physician and mailed by him/her to the Teachers' Retirement Fund Board of Trustees. Applicant must make any payment for this statement. This statement must be filed before a disability application will be considered.

Your Social Security number is requested by this agency in accordance with the requirements of IRS Code 3405. Disclosure is mandatory; this form will not be processed without this information.

Patient Name (Last, First, Middle)

PRIVACY NOTICE Social Security Number

TRF Number

Date of Birth (MM/DD/YY)

Marital Status (circle one) Married Single

Sex (circle one) Male Female

Phone Number

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How long have you personally known patient?

PATIENT HISTORY Date of your first visit with patient for illness claimed to have brought about present condition? Date of last visit?

Number of visits?

What organ, system, or parts of the body have been attacked?

Describe fully the course of the disease--its initial symptoms--history of its progress.

Has patient suffered from any ailments other than those above mentioned? If so, describe each case, and state how long it lasted and if recovery was complete?

Has patient been attended to or prescribed for by any other physician or surgeon with-in three years? If so, what was the reason? Give name and addresses of all such physicians and surgeons:

Is patient wholly and continuously unable to perform any work, or follow any occupation for compensation or profit?

If so, how long has patient been totally disabled?

CONTINUED ON REVERSE SIDE

If not so disabled, is patient wholly and continuously unable to perform the work of a public school teacher?

Is the disability, in your opinion, likely to be temporary; permanent and total; or permanent and partial?

Please give any other facts or information, which in your judgment will aid in the correct solution of the claims presented.

How long have you practiced as a physician and where did you receive your medical education?

Signature of Physician

Printed Name of Physician

Date

Signature of Patient for the release of this information

Printed Name of Patient

Date

Address of Physician

City

State

ZIP

Phone Number

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