Fillable Attending Physicians Report of Disability Tennessee Consolidated Retirement (State of Tennessee)

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Attending Physicians Report of Disability Tennessee Consolidated Retirement (State of Tennessee)

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TR-0056 (Rev. 6/12) RDA-413
Page 1 of 5
Attending
Physician’s
Report of Disability
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
1-800-770-8277 treasury.tn.gov/tcrs
ATTENTION APPLICANT AND PHYSICIAN:
• This is an authorization requested by the applicant in order that discussion of any and all information
concerning the applicant’s disability may be freely given to the TCRS.
• The expense of furnishing this information must be paid by the applicant.
• In addition to the completion of this form, the physician is requested to attach all offi ce notes, hospital
summaries, test results and any other medical information available.
SECTION 1. MEMBER INFORMATION
Member ID Last 4 SSN XXX-XX- Date of Birth
Full Name Gender
Male Female
Mailing Address
City State Zip Code
Email Phone Number
Applicant’s Signature Date
SECTION 2. TO BE COMPLETED BY PHYSICIAN (Complete only the parts that are applicable. Give
results or descriptions.)
Physician’s Full Name
Physician’s Mailing Address
City State Zip Code Phone Number
Patient’s Current Height feet inches Patient’s Current Weight Pounds
When were you fi rst consulted regarding the present illness?
Are you currently attending the applicant?
Yes No
If not, please indicate the reason why you are no longer attending the applicant:
TR-0056 (Rev. 6/12) RDA-413
Page 2 of 5
SECTION 2. TO BE COMPLETED BY PHYSICIAN (Complete only the parts that are applicable. Give
results or descriptions.)
Diagnosis of Primary Impairments:
Diagnosis of Secondary Impairments:
Musculoskeletal System:
X-Ray Findings:
Limitation of Motion and the Degree:
Comment on History of Pain, Swelling and Stiffness:
Respiratory System:
Chest X-Ray Findings
Pulmonary Function / Arterial Blood / Gas Studies:
In the Case of Pulmonary Tuberculosis, Provide Sputum Culture Results:
Cyanosis / Dyspnea:
TR-0056 (Rev. 6/12) RDA-413
Page 3 of 5
SECTION 2. TO BE COMPLETED BY PHYSICIAN (Complete only the parts that are applicable. Give
results or descriptions.)
Cardiovascular System:
EKG / Enzyme Studies:
Blood Pressure Readings:
Chest X-Ray, Including Cardio-Thoracic Ratio:
Chest Pain and Medication Used to Relieve Pain:
Edema, Pigmentation, Cyanosis or Ulceration:
End-Organ Damage as a Result of Hypertension:
Indicate New York Heart Classifi cation:
Mental Disorders:
Impairment of Memory, Judgment/Ability to Perform Calculations:
Reduction in Daily Activities, Interests, Personal Habits and Ability to Relate to Others:
Does the Applicant Demonstrate the Ability to Relate to and Communicate with Supervisors and Co-Workers in
a Work Situation?
Yes No
Explain:
TR-0056 (Rev. 6/12) RDA-413
Page 4 of 5
SECTION 2. TO BE COMPLETED BY PHYSICIAN (Complete only the parts that are applicable. Give
results or descriptions.)
Hearing:
Results of Audiological Evaluation (with hearing aid):
Visual:
Best Corrected Visual Acuity and Visual Fields:
Digestive:
Liver Studies, X-Ray Findings, Endoscopy / Barium Enema Studies, Weight Loss:
Genito-Urinary:
BUN / Creatine Clearance, Report of Dialysis Treatment:
Hemic and Lymphatic:
Complete Blood Count:
Endocrine:
Diabetes, Evidence of Neuropathy, Acidosis, Amputations / Ophthalmological Changes:
TR-0056 (Rev. 6/12) RDA-413
Page 5 of 5
SECTION 2. TO BE COMPLETED BY PHYSICIAN (Complete only the parts that are applicable. Give
results or descriptions.)
Neurological:
EEG and Describe Motor Limitations:
Neoplasms:
Biopsy and Operative Reports, Severity and Extent of Lesion:
Prognosis:
Based on your recommended treatment, give degree of improvement that can reasonably be anticipated along
with approximate period of time required to achieve this improvement:
The impairment has or is expected to last 12 continuous months?
Yes No
Has the impairment prevented performance of past work?
Yes No
Does the impairment prevent engagement in all other gainful employment?
Yes No
If not, please indicate the type of work the applicant is capable of performing:
Heavy Medium
Light Sedentary
Include any hospitalization records, including discharge summary:
Physician’s Signature Date
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Attending Physicians Report of Disability Tennessee Consolidated Retirement (State of Tennessee)

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Completed 27 January 2021

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