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WICHITA STATE UNIVERSITY |
Office of Financial Aid
| Jardine Hall Rm. 203 | 1845 Fairmount Street | Wichita, KS 67260-0024
tele: (316) 978-3430 | toll free:
1-855-WSU1STP (978-1787)| fax: (316) 978-3396 | web: www.wichita.edu/financialaid
PHYSICIAN’S INSTRUCTIONS >>>
General Information
This form is used to obtain a physician’s certification and a borrower’s acknowledgment. The purpose is to have a licensed
physician certify that the borrower is able to engage in substantial gainful activity and to have the borrower acknowledge
that any federal student loans received as a result of this physician’s certification cannot be canceled based on any present
impairment or condition, unless that impairment or condition substantially deteriorates to the extent that the definition of
total and permanent disability is met. This form will allow the borrower to secure additional loan(s) under one or more of
the following Federal Loan Programs: Stafford Loans, PLUS Loans for Parents, PLUS Loans for Graduate Students,
Consolidation Loans and Federal Perkins Loans.
Definition of Total and Permanent Disability
To be totally and permanently disabled, the borrower must be unable to work and earn money or attend school because of
an injury or illness that is expected to continue indefinitely or result in death. This definition calls for a judgment decision
as to the borrower’s ability to earn income despite his or her disability. The physician is to assess the impact of the borrower’s
disability on his or her ability to earn income in light of what the borrower would normally be able to earn if he or she were
not disabled. If the disability appears to have a significant adverse effect the borrower’s earning potential, not only in the
type of work performed before the impairment but for any substantial gainful employment, and the disability is expected
to last for a long and indefinite period of time, then the borrower shall be considered permanently disabled under this
definition. If, however, the borrower’s condition has improved so that the borrower is able to engage in substantial gainful
activity or attend an institution of postsecondary education, a reaffirmation (reinstatement, no longer in discharge status)
can be processed to allow the borrower to complete procedures for eligibility for Title IV (federal) student aid.
Privacy Act Notice: The Privacy Act of 1974 (5 U.S.C. 522a) requires that an agency provide the following notice to each
individual whom it asks to supply information.
The authority for collecting the information requested on this form is found in 20 U.S.C. 1087, 42 U.S.C. 209 4k and 22 U.S.C.
2601.
The principal purpose of this information is to verify the identity of the borrower; determine that the borrower is able
to engage in substantial gainful activity, and in the event it is necessary, to locate the borrower’s certifying physician.
The routine uses of this information include its disclosure to Federal, State or local agencies, to guaranty agencies,
to educational and financial institutions and to agency contractors for the purpose of: verifying the identity of the
borrower and the borrower’s physician; determining that the borrower is able to engage in substantial gainful
activity; investigating possible fraud and verifying compliance with program regulations. Failure to provide the
requested information may result in denial of the borrower’s new loan request.
This information is necessary to process requests for new Federal Loan Programs.
*Source: U.S. Department of Education, “Physician Certification and Borrower’s Acknowledgment of Obligation,” 7-99 (L-54). WSU Revised 3/2014
TO BE COMPLETED BY CERTIFYING OFFICIAL >>>
Physician’s Certification (Check one)
I certify that in my professional medical judgment, the patient/borrower named above is able to engage in
substantial gainful activity and can attend school. (Refer to Physician’s Instructions below).
In my professional medical judgment of the patient/borrower named above, I cannot certify that he/she is able to
engage in substantial gainful activity and can attend school. (Refer to Physician’s Instructions below).
>>> Date borrower became able to work and earn wages (MM DD YYYY): __ __ / __ __ / __ __ __ __
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Name of Physician (Last, First, MI) State of Legal Authorization to Practice Medicine
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Physician’s Address (City, State, Zip) Phone Number
_____________________________________________________ ___________________________
Physician’s Signature (M.D. or D.O.) Date Physician’s License Number
