How often did you see this physician?
Date first 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.
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:
4. Date of Birth
3. Social Security Number
2. First/Middle Name
1. Last Name & Suffix
Form 6251Revised 6/3/2016Please 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
Scripting must be enabled for this form to work correctly.