DMS Federal Disability Retirement IMO Intake Form

Thank you for considering David Medical Services for your independent medical opinion. Our evaluations are objective, evidence-based medical opinions intended to assist federal employees pursuing disability retirement under FERS or CSRS.

This intake form provides our physician with important information regarding your request for an independent medical opinion in support of a federal disability retirement request. The independent medical opinion is based on record review; it does not guarantee approval and does not constitute advocacy or legal representation.

Who Is Completing This Form?* This field is required.

Employee

Attorney

Family member

Union representative

Other

Legal Name* This field is required.

First name

Last name

Date of Birth* This field is required.

Date

Email Address* This field is required.

example@example.com

Phone Number* This field is required.

Please enter a valid phone number.

Current State of Residence * This field is required.

Preferred Method of Contact

Phone

Either method is fine

Federal Agency* This field is required.(e.g., VA, DoD, DHS, DISA, etc.)

Department or Bureau* This field is required.

Your Official Position Title* This field is required.

Occupational Series

Grade (GS / WC / etc.)

Years in Federal Service* This field is required.

Years in Current Position* This field is required.

Supervisor's Position Title* This field is required.

Employment Status* This field is required.

Working Full Time

Working Part Time

LWOP

FMLA

Sick Leave

Administrative Leave

Separated

Retired

Other

Description of Essential Job Functions* This field is required.Please describe the core duties of your position that are affected by your medical condition. Please also email a copy of your current Official Position Description (PD). If you do not have a copy, we can often proceed initially, but it may be requested later.

What Are Your Most Important Duties?* This field is required.

How Much of Your Day Involves the Following Activities?* This field is required.

Which Best Describes Your Situation?* This field is required.

I'm considering applying

I'm preparing an application

My OPM application is pending

My OPM application was denied

My MSPB appeal is pending

My attorney requested an evaluation

Other

Have You Previously Applied?* This field is required.

YESNO

If You Have Previously Applied, When Did You Apply and What Was the Outcome?

What Medical Condition(s) Are Preventing You from Performing Your Job?* This field is required.List provider-diagnosed medical condition(s) only, and the approximate year you were diagnosed with the condition.

Which ONE Condition is the Primary Reason You Can No Longer Perform Your Job?* This field is required.

When Did Your Symptoms Begin, and How Have Your Symptoms Changed Over Time?* This field is required.

When Did Your Symptoms Begin Affecting Your Work?* This field is required.Please provide approximate month and year.

Treating Provider or Clinician

What Treatment Are You Receiving for Your Condition(s)?* This field is required.List current treatment (medications, therapeutic modalities, etc.)

Have Any of Your Treating Providers Indicated That Your Condition Is Expected to Last at Least One Year or Is Unlikely to Substantially Improve with Additional Treatment?* This field is required.

Yes

Unsure

How Does Your Primary Disabling Medical Condition Interfere with Your Ability to Perform Your Job?* This field is required.Check all that apply.

Unable to sit

Unable to stand

Unable to walk

Unable to lift

Pain

Fatigue

Memory problems

Anxiety

Panic attacks

Sleep impairment

Medication side effects

Driving limitations

Travel limitations

Frequent absences

Other

Describe the Specific Job Duties You Can No Longer Perform.* This field is required.

Approximately How Much Work Have You Missed During the Past 12 Months?* This field is required.Choose one.

None

1-5 days

6-20 days

More than 20 days

Primarily LWOP

Primarily FMLA

Primarily sick leave

Other

How Has Your Medical Condition Negatively Affected Your Work Performance?* This field is required.

Missed deadlines

Reduced productivity

Difficulty concentrating

Errors

Difficulty interacting with coworkers

Difficulty completing assignments

Other

Have You Ever Requested Reasonable Accommodations?* This field is required.

YESNO

Were the Accommodations Approved?* This field is required.

YESNO

If the Accommodations Were Approved, Were They Effective?

YESNO

If the Accommodations Were Denied, What Was the Reason?

Do You Currently Telework?* This field is required.

Occasionally

Hybrid

Yes, I telework full-time

What Was the Last Date You Were Able to Perform All of the Essential Functions of Your Position WITHOUT Medical Restrictions?* This field is required.Approximate date is acceptable.

Date

Has Your Agency Discussed Reassignment?* This field is required.

Yes

Unsure

Have You Ever Applied for:* This field is required.

Social Security Disability

VA Disability

Workers' Compensation

State Disability

Private Disability Insurance

Other

Medical records you plan to submitCheck all that apply.

Functional Capacity Evaluation (FCE)

VA medical records

Private medical records

Imaging / lab reports

Operative reports

Neuropsychological testing

Mental health treatment records (if applicable)

Other

Approximate Number of Pages You Expect to Submit.* This field is required.Additional fees may apply for extensive record review. Please plan to submit only records relevant to this request; unrelated records may delay review.

Less than 25 pages

25-50 pages

More than 50 pages

Acknowledgment of Scope* This field is required.

I understand that this service provides an independent medical opinion based on available records.

I understand the physician's opinion will be based upon an objective review of the medical evidence.

I understand this is not advocacy, not legal advice, and does not guarantee approval of my accommodation request.

I understand that additional fees may apply for extensive record review.

I understand that this service provides an independent medical opinion only and does not establish a physician–patient relationship or provide medical treatment.

I certify the information provided is true and complete to the best of my knowledge.

What Assistance Are You Seeking?* This field is required.Our physician will determine the appropriate evaluation level after reviewing the nature of your request, procedural stage, record volume, and complexity of the medical and occupational issues.

Initial medical records and case assessment

Independent medical evaluation

Federal disability retirement medical narrative

Response to an OPM request for additional evidence

Review of an OPM denial

Reconsideration medical opinion

MSPB expert medical report

Other

What Are You Hoping Our Physician Can Help Clarify or Explain in Your Disability Retirement Application?Optional

Date submitted(Today's date)

Date

Please verify that you are human* This field is required.

DMS Federal Disability Retirement IMO Intake Form