New Hampshire Code of Administrative Rules
Ret - Board of Trustees of the N.H. Retirement System
Chapter Ret 500 - FILING OF FORMS
Part Ret 502 - FORMS AND FILING REQUIREMENTS
Section Ret 502.10 - Filing of the Treating Physician's Statement
Universal Citation: NH Admin Rules Ret 502.10
Current through Register No. 12, March 21, 2024
(a) In all cases of disability retirement, the member shall obtain an evaluation of the member's condition from the member's treating physician and file the evaluation form with the system.
(b) The medical evaluation form completed by the treating physician shall provide the following information:
(1) The applicant's
name and Social Security number;
(2) The physician's or practitioner's name,
specialty, board certification, office address and telephone number;
(3) Where he or she is licensed to practice
medicine and treatment history;
(4)
The applicant's diagnosis(es);
(5)
The applicant's functional capacity and limitations;
(6) The applicant's ability or inability to
perform the essential functions of the job;
(7) Recommendations for additional treatment;
and
(8) The projected duration of
the applicant's impairment.
(c) The treating physician shall complete the certification section by:
(1) Dating
it;
(2) Checking the appropriate
box to indicate total incapacity from the duties contained in the member's job
description and permanency of that incapacity; and
(3) Signing it.
#7574, eff 10-10-01, EXPIRED: 10-10-09
New. #9563, eff 10-14-09
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