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CSS2HTML: WEB6291.XDP

ZIP+4

City

Address

Social Security Number

First/Middle Name

Last Name & Suffix

Form 6291
Revised 7/11/2012

Page 1

Print or type in black ink

State

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

Telephone Number

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 Seen:

Telephone Number:

Physician's Name:

Mailing Address:

Dates of Treatment:

Name of Facility:

Address:

Initial

CDR

No

Yes (describe)

No

Yes (please describe)

No

Yes (provide the following information)

No

Yes (please complete the following):

In-patient

Out-patient

Text Field

ADMINISTRATIVE APPEAL DISABILITY REPORT

SC Public Employee Benefit Authority

South Carolina Retirement Systems

Post Office Box 11960

Columbia, SC 29211-1960