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Attending Physician's Statement

About this Form

Form number: 455-25

Audience:  Attending Physician

Last revised: July 2016

INSTRUCTIONS: To be completed by the attending physician when an employee is applying for disability retirement. Complete this form, sign and return to the Employee and Retiree Service Center (ERSC). You may fax form to 301-279-3642/301-279-3651 or e-mail an electronically signed Adobe PDF file to

Adobe PDF Attending Physician's Statement112 KEnglish

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