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PERAC Disability Forms

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Disability Forms for Members

Authorization to Use or Disclose Protected Health Information (English, PDF 53.76 KB)
Disability Application Glossary of Terms (English, PDF 126.97 KB)
Disability Retiree Earned Income Worksheet (English, PDF 172.83 KB)
Disability Retirement Application (English, PDF 433.55 KB)
Disability Retirement Benefits for Veterans (English, PDF 104.73 KB)
Instructions for Submitting the Annual Statement of Earned Income (English, PDF 124.94 KB)
Waiver of Applicant Attendance at Medical Panel Examination During COVID-19 Pandemic (English, PDF 329.47 KB)

Disability Forms for Administrators

Accidental Disability Retirement Checklist (English, PDF 85.8 KB)
Disability Retiree Current Information Form (English, PDF 207.06 KB)
Disability Retirement Application (English, PDF 433.55 KB)
Disability Transmittal to the Commission (English, PDF 242.79 KB)
Notice of Retirement Board Action on Disability Application (English, PDF 73.17 KB)
Notice to PERAC of Reinstatement of Duties (English, PDF 245.59 KB)
Physician's Statement Pertaining to a Member's Disability Retirement Application (English, PDF 276.36 KB)
Waiver of Applicant Attendance at Medical Panel Examination During COVID-19 Pandemic (English, PDF 334.3 KB)

Disability Forms for Employers

Employer Statement for Disability Retirement Application (English, PDF 333.61 KB)
Involuntary Retirement Application (English, PDF 311.79 KB)
Waiver of Applicant Attendance at Medical Panel Examination During COVID-19 Pandemic (English, PDF 332.07 KB)

Disability Forms for Physicians

Commonwealth Terms and Conditions (English, PDF 62.04 KB)
Massachusetts Substitute W-9 Form (English, PDF 270.4 KB)
Regional Medical Panel Certificate (English, PDF 517.28 KB)

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