Retirement Application

Retirement Application

For Members Applying for an Ordinary or Accidental Disability Retirement

Members applying for an Ordinary or Accidental Disability Retirement must also submit all required supporting hospital and physician records. At least two corroborating pieces of medical documentation and the Authorization for Release of Information (HIPAA) form are required:

•	Statements from at least two treating physicians, or;
•	A statement from one treating physician and records from a hospital stay related to the disability; and
•	Member completion of the required Authorization for Release of Information (HIPAA) form.

Members must submit the required medical documentation using the forms provided below:

Medical Examination by Personal or Treating Physician
Adobe PDF - Click here to access and print

Use this form to obtain written statements from your treating physician(s).

Authorization to Disclose Hospital Records
Adobe PDF - Click here to access and print

Complete this form and forward it to the hospital where treatment for the disability occurred, in order to request the release of your hospital records.

Authorization for Release of Information (HIPAA)
Adobe PDF - Click here to access and print

Complete this form and return it to the Division of Pensions and Benefits.

It is your responsibility to ensure that all required forms are submitted!
The more complete your medical documentation, the better able the
Medical Review Board will be to make a fully informed determination.
Failure to submit ALL medical documentation will result in the delay of processing your retirement benefit.

Close Window