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
