(APPLICANT: Do not write on this side; please complete the authorization form on the reverse side.) 
 

TO:   Chief Justice                                                       SUBJECT:   Physician’s Report of Disability in the case of: 
         Alabama Supreme Court 
         ℅ Alabama Office of Courts                                                     Sex:            Male            Female 
         Legal Division                                                                           Date of Birth: 
           300 Dexter Avenue                                                                   Height:                                   Weight 
           Montgomery, AL 36104                                                            Blood Pressure:                     Urinalysis:  

   

tate of Alabama 

Unified Judicial System 

orm PERS-59      Rev. 4/07 

PHYSICIAN’S REPORT OF DISABILITY 
(TO BE COMPLETED AND SIGNED BY DOCTOR) 
(Please Type) 

 

                     This is to certify that the above named person has been under my professional care for this condition since 
                                                                                              and  was last seen on      
                 Month              Day                  Year                                                                                           Month                 Day                Year 

             The subjective and objective symptoms of which said person complains are as follows: 

CHIEF COMPLAINT  AND DURATION:  (In Detail) 
 

EDICAL HISTORY:  

            Give nature and dates of surgical procedure; if any. (Describe fully)   
 

            Give nature and dates of other (non-surgical) treatment, if any. (Describe fully) 
 

              Is patient still under your care for this condition? If “no”, give date your service terminated. 
                                  
                                            Yes                    No                                                          
                                                                                                                                        Month                              Day                        Year 

  S

  F

 

   

              D

 

            M

             

             

         

   

IAGNOSIS:  (In Detail) 

PROGNOSIS:  (In Detail) 

Form PERS-59 (back)      Rev. 4/07 

PHYSICIAN’S REPORT OF DISABILITY 

ISABILITY DETERMINATION: In order to qualify for disability retirement, Chapter 18 of Title 12, Code of Alabama 1975, requires that 

statements must be obtained from three reputable physicians verifying that in their professional medical opinion the above named applicant is “permanently 
physically and/or mentally unable to carry out the duties of his/her office on a full time basis” and should be retired because of medical disability.  If you have 
made this finding, please expressly indicate by including your statement in the space below. 
 

This report must be signed personally by physician. 

  

   

 

                                                                                                               Signature 
Sworn to and subscribed before me this 
                                                                                                               Name 
Date: 
                                                                                                                                           Street Address 

                                                                                                                                          City                                       State                         Zip 
Notary Public 
                                                                                                                                           Telephone Number 

OTE:   Section 36-27-27, Code of Alabama 1975, states: Any person who makes a false statement or falsifies a record in any attempt to defraud the Retirement Systems 

shall be guilty of a misdemeanor, and upon conviction, be punished by fine up to $500.00 and/or imprisonment not to exceed one year. 

 
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION 
(To be Completed and Signed by Applicant) 
 

TO:    Dr.                                                                                                           DATE: 
                                                                                                                                           Month           Day         Year 
             
              Street Address 

             City                                  Sate                                  Zip 

Dear Doctor: 
           
            You are hereby authorized and requested by me to complete the form on the reverse side of this sheet, have it 
notarized and forward it along with supporting documentation to the Administrative Office of Courts. 

ame of Applicant                                                                                                              Signature of Applicant 

itle                                                                                                                                       Street Address 

ocial Security Number                                                                                                       City                         State                           Zip 

         I am a licensed physician in the State of                                                                Date 
Specialty                                                                                                                      Board Certified? 

         I graduated from 
Medical School located in                                                                                                               Year 

         Are you related to the patient by blood or marriage? If “yes” state relationship. 

EMARKS: (Give any information of value not included above.) 

  D

             

       

 

  R

 

   

   

  

 

 

   

  N

   

      N

  T

  S