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 ERSC@mcpsmd.org.
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