Section Ret 502.10 - Filing of the Treating Physician's Statement(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: (2) Checking the appropriate box to indicate total incapacity from the duties contained in the member's job description and permanency of that incapacity; andN.H. Admin. Code § Ret 502.10
#7574, eff 10-10-01, EXPIRED: 10-10-09
New. #9563, eff 10-14-09