In order to determine if your patient is eligible for benefits under the retirement law, we need information regarding the patient's current medical condition.
1. Diagnosis of disability:
2. Estimate of the expected
date of full or partial
recovery:
3. Age at onset: 4. Severity of disability: 5. If patient is mentally
retarded, state
approximate mental age:
6. If patient is mentally
retarded, give results
of IQ tests:
Mild
Moderate
Severe
In addition, please attach a narrative (on your letterhead stationery) addressing the following points:
1. The history of the specific medical condition(s), including references to findings from previous examinations, treatment, and responses to
treatment.
2. Clinical findings from your most recent medical evaluation, including findings of physical examinations, results of laboratory tests, X-rays,
EKG's and other special evaluations or diagnostic procedures and, in the case of psychiatric disease, the findings of mental status examinations
and the results of psychological tests.
3. Assessment of the current clinical status and plans for future treatment.
4. Assessment of the degree to which the medical condition has or has not become static, well stabilized, or controlled, and an explanation of the
Address
Signature
Part B. To Be Completed by the Physician
medical basis for the conclusion.
5. Specify the physical and/or mental limitations or restrictions caused by the patient's medical condition(s).
6. Does the patient's condition preclude or limit self-supporting employment? Explain your answer.
7. If the patient is incapable of self-support, at what age did the patient become incapable?
8. Can the patient handle his or her own finances?
Print or type name Date
Telephone number
(including area code)
Return the completed form and the narrative to the address on the front of the form.
Public Burden Statement
We estimate this form takes an average 60 minutes per response to complete, including the time for reviewing instructions, getting the needed data, and
reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion
time, to the Office of Personnel Management (OPM), Retirement and Benefits Publications Team (3206-0179), Washington, DC 20415-3430. The OMB
Number, 3206-0179 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Privacy Act Statement
Title 5, U.S. Code, Chapters 83, 84, and 89, authorize solicitation of this information. The data you furnish will be used to determine whether the disabled
dependent is eligible for continued benefits. This information may be shared and is subject to verification, via paper, electronic media, or through the use
of computer matching programs, with national, state, local, or other charitable or social security administrative agencies to determine benefits under their
programs, to obtain information necessary for determination or continuation of benefits under this program, or to report income for tax purposes. It may
also be shared and verified, as noted above, with law enforcement agencies when they are investigating a violation or potential violation of civil or
criminal law. Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number. Provision of this information is voluntary;
however, failure to supply all of the requested information may result in our inability to allow benefits.
Reverse of RI 30-10
Revised June 2010
