You must be a licensed medical or osteopathic physician to fill out this form. If you live in Puerto Rico, please provide proof of license.

• Complete all fields in full.
• Provide a complete diagnosis.
• Explain in detail how illness prevents your patient from working or earning money in any capacity.
• Use MM/DD/YYYY format for all dates.
• Sign and date the form; provide your full name, full mailing address, and phone number.
• If you alter any parts of Section 3, please provide a letter detailing the reasons.