State of Alabama
Unified Judicial System
Form PERS-59 Rev. 4/07
PHYSICIAN’S REPORT OF DISABILITY
(TO BE COMPLETED AND SIGNED BY DOCTOR)
(Please Type)
(APPLICANT: Do not write on this side; please complete the authorization form on the reverse side.)
TO: Chief Justice SUBJECT: Physician’s Report of Disability in the case of:
Alabama Supreme Court
Alabama Office of Courts
Sex: Male Female
Legal Division
Date of Birth:
300 Dexter Avenue
Height: Weight
Montgomery, AL 36104
Blood Pressure: Urinalysis:
This is to certify that the above named person has been under my professional care for this condition since
and was last seen on
Month Day Year Month Day Year
The subjective and objective symptoms of which said person complains are as follows:
CHIEF COMPLAINT AND DURATION:
(In Detail)
DIAGNOSIS:
(In Detail)
PROGNOSIS:
(In Detail)
MEDICAL HISTORY:
Give nature and dates of surgical procedure; if any. (Describe fully)
Give nature and dates of other (non-surgical) treatment, if any. (Describe fully)
Is patient still under your care for this condition? If “no”, give date your service terminated.
Yes No
Month Day Year
Form PERS-59 (back) Rev. 4/07
PHYSICIAN’S REPORT OF DISABILITY
DISABILITY DETERMINATION:
In order to qualify for disability retirement, Chapter 18 of Title 12, Code of Alabama 1975, requires that
statements must be obtained from three reputable physicians verifying that in their professional medical opinion the above named applicant is “permanently
physically and/or mentally unable to carry out the duties of his/her office on a full time basis” and should be retired because of medical disability. If you have
made this finding, please expressly indicate by including your statement in the space below.
REMARKS:
(Give any information of value not included above.)
I am a licensed physician in the State of Date
Specialty Board Certified?
I graduated from
Medical School located in Year
Are you related to the patient by blood or marriage? If “yes” state relationship.
This report must be signed personally by physician.
Signature
Sworn to and subscribed before me this
Name
Date:
Street Address
City State Zip
Notary Public
Telephone Number
NOTE: Section 36-27-27, Code of Alabama 1975, states: Any person who makes a false statement or falsifies a record in any attempt to defraud the Retirement Systems
shall be guilty of a misdemeanor, and upon conviction, be punished by fine up to $500.00 and/or imprisonment not to exceed one year.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
(To be Completed and Signed by Applicant)
TO: Dr. DATE:
Month Day Year
Street Address
City Sate Zip
Dear Doctor:
You are hereby authorized and requested by me to complete the form on the reverse side of this sheet, have it
notarized and forward it along with supporting documentation to the Administrative Office of Courts.
Name of Applicant Signature of Applicant
Title Street Address
Social Security Number City State Zip