Social Security Number
Last Name & Suffix
Form 6291Revised 7/11/2012Page 1Print or type in black ink
1. I do not agree with the decision made on my claim because:
2. Has there been a change (for better or worse) in your illness or injury since you filed your claim?
3. Do you have any additional illnesses or injuries?
FOR OFFICE USE ONLY
Date of Birth
4. Have you seen a physician since you last completed a disability report?
5. Have you been hospitalized or treated at a clinic?
Reason for visit(s):
Reason for Treatment:
Dates of Treatment:
Name of Facility:
ADMINISTRATIVE APPEAL DISABILITY REPORT
SC Public Employee Benefit Authority
South Carolina Retirement Systems
Post Office Box 11960
Columbia, SC 29211-1960
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