Heal Form 539 - Physician'S Certification Of Borrower'S Total And Permanent Disability - U.s. Department Of Education
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1
2U.S. DEPARTMENT OF EDUCATION
OMB Control No. 1845-0124
Federal Student Aid
Expiration Date: 9/30/2016
PHYSICIAN'S CERTIFICATION OF BORROWER'S TOTAL AND PERMANENT DISABILITY
PRA Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. The valid OMB control number for this information collection is 1845-0124. Public reporting burden for this
collection of information is estimated to average 5 minutes for the borrower, 10 minutes for the lender, and 30 minutes for the physician per response,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. The obligation to respond to this collection is required to obtain or retain benefit (Title VII, Part A, Subpart I of the Public Health
Service Act (42 U.S.C. 294m) and the Consolidated Appropriations Act, 2014). If you have comment or concerns regarding the status of your individual
submission of this form, please contact the HEAL Program , U.S. Department of Education, 830 First Street NE, Washington, DC 20202 directly.
[Note: Please do not return the completed form to this address.]
WARNING: ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT OR MISREPRESENTATION ON THIS FORM MAY BE SUBJECT TO FINE OR IMPRISONMENT
UNDER SECTION 1001 OF THE UNITED STATES CRIMINAL CODE.
GENERAL INSTRUCTIONS
This form is used for obtaining a physician's certification of a borrower’s permanent and total disability for the purpose of cancellation of the borrower’s obligation to repay his or her student
loan(s) obtained under the Health Education Assistance Loan (HEAL) program.
DEFINITION OF TOTAL AND PERMANENT DISABILITY
TO BE TOTALLY AND PERMANENTLY DISABLED THE BORROWER MUST BE UNABLE TO ENGAGE IN ANY SUBSTANTIALLY GAINFUL ACTIVITY
BECAUSE OF A MEDICALLY DETERMINABLE IMPAIRMENT THAT IS EXPECTED TO CONTINUE FOR A LONG AND INDEFINITE PERIOD OF TIME OR TO
RESULT IN DEATH
.
It should be noted that the standard for determining disability for cancellation of the borrower's loan obligation may be different from standards used under other public and private
programs in connection with occupational disability or eligibility for social service benefits.
INSTRUCTIONS FOR BORROWER
INSTRUCTIONS FOR PHYSICIAN
1.
Complete Section I and sign the form. A representative of the
PLEASE NOTE: Complete this form only If you are a doctor of medicine or a doctor
borrower may complete this section and sign the form on the
of osteopathy legally authorized to practice in your state
borrower's behalf if the borrower is unable to do this because of his or
1.
Complete Section II and sign the certification only If the borrower's condition
her disability.
meets the above definition of total and permanent disability. Please make
2.
Have Section II of the form completed and signed by a doctor of
your report complete, as to the nature, duration and severity of the
medicine or doctor of osteopathy.
borrower's present and future impairment. You may attach additional pages
3.
Return a completed copy(s) of this form to each lender which has
if necessary.
made a loan to you under the Health Education Assistance Loan
2.
Current Medical Evaluation (Not more than 4 months old): Report should be
(HEAL) program.
detailed to provide for a comprehensive review to determine the nature,
duration, and extent of the impairment. Include supporting documentation
Before sending to lender, please, make sure that Section II
on the history of the illness, medical examinations, and inpatient/outpatient
(Certification of Borrower's Total and Permanent Disability) has
treatments, current medications, past medical records and a prognosis and
been completed.
rehabilitation plan.
3.
Return this form to the borrower listed in Section I.
Section I – TO BE COMPLETED BY BORROWER OR BORROWER’S REPRESENTATIVE
(See instructions above. See Privacy Act notice on reverse side.)
NAME OF BORROWER (Last)
(First)
(MI)
BORROWER’S SOCIAL SECURITY NUMBER
NAME AND ADDRESS OF BORROWER OR BORROWER’S REPRESENTATIVE (Print or type)
AGE OF BORROWER
DATE OF BIRTH
MM
DD
YYYY
________/_________/_________
GRADUATION DATE
COURSE OF STUDY
DATE ENTERED HEAL SCHOOL
MM
DD
YYYY
MM
DD
YYYY
_________/_________/__________
_________/__________/___________
EMPLOYMENT HISTORY (since separation from school)
I authorize any physician, hospital or other institution having records pertaining to the disability for
CONSENT FOR RELEASE OF INFORMATION –
which I am requesting discharge of my loan(s) to make information from such records available to the Departments of Education and Health and
Human Services and to the holder of my loan(s). I authorize the Department of Health and Human Services designated physician to contact my
physician(s) to receive my medical records and discuss my medical condition.
SIGNATURE OF BORROWER OR REPRESENTATIVE
DATE
MM
DD
YYYY
____________/___________/_____________
See Back for Sections II and III
HEAL Form 539 (Front)
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