Pa Schedule Ps - Physician'S Statement Of Permanent And Total Disability - 2001
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1PA SCHEDULE PS
0105510051
Physician’s Statement of Permanent
and Total Disability
PA-1000 PS (09–01)
2001
OFFICIALUSE ONLY
PA Department of Revenue
Name as shown on PA-1000
Social Security Number
START
Instructions
A claimant that is not covered under the Federal Social Security Act or the Federal Railroad Retirement Act, and that is
unable to submit proof of permanent and total disability, may submit this physician’s statement. The physician must
determine the claimant’s status using the same standards used for determining permanent and total disability under the
Federal Social Security Act or the Federal Railroad Retirement Act. CAUTION. If the claimant applied for Social
Security disability benefits, but the Social Security Administration did not rule in the claimant’s favor, the claimant is not
eligible for a Property Tax or Rent Rebate check as a disabled person.
Confidentiality Statement. All information on this physician’s statement and claim form is confidential. The
Department shall only use this information for the purposes of determining the claimant’s eligibility for a Property Tax or
Rent Rebate check.
CERTIFICATION
I certify that the claimant named above is my patient and is permanently and totally disabled under the standards that
the Federal Social Security Act or the Federal Railroad Retirement Act requires for determining permanent and total
disability. Upon request from the PA Department of Revenue, I will provide the medical reports or records indicating
diagnosis and prognosis of the claimant’s condition, including signs, symptoms, and laboratory findings if applicable or
appropriate.
The Department does not accept electronic signatures.
Physician Signature
Date
Description of Claimant’s Permanent and Total Disability. Briefly describe the reason(s) that the above named
claimant is totally and permanently disabled.
Physician Identification Information. Please print:
Name:
Business Name, if applicable:
Address:
City:
State:
ZIP Code:
Office telephone number:
Office e-mail address:
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