2.Physician's name:

Address:

Telephone: 

How often did you see this physician?

Date first seen:

Treatment Received:

1.Physician's name:

Address:

Telephone: 

How often did you see this physician?

Date first seen:

Treatment Received:

Date last seen:

Date last seen:

   A)  Please list the names, addresses, and telephone numbers of physicians who have your current medical records.  Or, submit any
         current medical records you have with this Disability Report.  If further medical evidence develops while your claim is being
         evaluated, please forward the documentation to the SCRS Medical Board. 

Section III

Year

Day

Month

If yes, when

If yes, when

If yes, when

If yes, when

g) Have you filed a Workers Compensation claim?        

f)  Has your disability resulted from an on the job injury? 

e) Have you applied for Social Security Disability benefits?

d) Have you returned to work ?

a) Describe your disability:

b) When did your disability prevent you from working? 

c) Explain why you stopped working:

Section II

8. State

9. ZIP+4

7. City

6.  Phone

5. Address

4. Date of Birth

3. Social Security Number

2. First/Middle Name

1. Last Name & Suffix

PERSONAL INFORMATION

Section I

Form 6251
Revised 6/3/2016
Please complete form

in blue or black ink.

Page 1

SC Public Employee Benefit Authority

South Carolina Retirement Systems

Member's Disability Report

(please complete all sections)

To be completed by member or legal representative