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

Applicant's 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.

Preferred method of contact

Phone

Either method is fine

State of residence * This field is required.

If outside the US, provide city and country

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.

Which federal retirement system covers your employment?* This field is required.

FERS

CSRS

CSRS Offset

Not sure

What is your current federal employment status?* This field is required.

Employed, full time

Employed, part time

On extended leave

Separated

Retired

Other

If you have separated from federal employment, what was your official separation date?

Date

Are you currently using any of the following leave arrangements?

Sick leave

Annual leave

Family and Medical Leave Act (FMLA)

Leave Without Pay (LWOP)

Administrative Leave

None

Other

Please describe the essential duties and responsibilities of your federal position, particularly those affected by your medical condition* This field is required.Examples may include computer work, decision-making, physical activity, interacting with others, meeting deadlines, travel, or supervising employees.

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

How much of your day involves the following activities?* This field is required.

What is the current status of your federal disability retirement application?* This field is required.

I'm considering applying

I'm preparing an application

My initial application submitted and pending with OPM

My initial application was denied and I'm preparing a reconsideration

My reconsideration is pending with OPM

My reconsideration was denied; I'm considering MSPB appeal

My MSPB appeal is pending

Other

Have You Previously Applied?* This field is required.

YESNO

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

Do you have a copy of the OPM denial or reconsideration decision explaining the reasons for the decision?

YESNO

What medical conditions 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 medical condition is the primary reason you are unable to perform the essential duties of your federal position?* This field is required.If more than one condition contributes significantly to your occupational limitations, please identify the primary condition here and list the additional conditions in the previous question.

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 your treating providers indicated that your medical condition is expected to continue for at least 12 months?* This field is required.

Yes

Unsure

Not discussed

Are there additional treatments, procedures, or therapies planned that could substantially improve your ability to work?* This field is required.

Yes

Unsure

If yes, briefly describe.

How does your medical condition interfere with your ability to perform your job?* This field is required.Check all that apply.

Difficulty with prolonged sitting

Difficulty standing

Difficutly walking

Difficulty with lifting or carrying

Pain affecting work activities

Fatigue or reduced endurance

Difficulty concentrating

Memory impairment

Anxiety or panic symptoms

Sleep-related impairment

Medication side effects

Difficulty driving or traveling

Unpredictable symptoms or flare-ups

Difficulty maintaining regular attendance

Other

Describe the specific essential job duties you cannot perform reliably or consistently because of your medical condition* This field is required.Please provide examples of how your symptoms interfere with these duties, including whether you can perform them only with difficulty, additional breaks, assistance, or restrictions.

Approximately how many workdays have you missed because of your medical condition during the past 12 months?* This field is required.Choose one.

None

1-5 days

6-20 days

21-60 days

More than 60 days

Unable to estimate

Other

How has your medical condition affected your work performance?* This field is required.

Missed deadlines

Reduced productivity

Difficulty concentrating

Errors

Difficulty interacting with coworkers

Difficulty completing assignments

Additional time required to complete tasks

More frequent breaks needed

Unable to maintain predictable attendance

Assistance from coworkers required to complete tasks

Difficulty sustaining full workdays

Other

Have you requested or received workplace accommodations because of your medical condition?* This field is required.

Yes

Unsure

What was the last date you were able to perform all of the essential functions of your original position WITHOUT medical restrictions?Approximate date is acceptable.

Date

Have You Ever Requested Reasonable Accommodations?

YESNO

What accommodations have been requested or provided?* This field is required.Select all that apply.

Telework

Modified work schedule

Reduced work hours

Additional breaks

Ergonomic equipment

Modified duties

Leave or intermittent leave

Assistive technology

Other

Were the Accommodations Approved?* This field is required.

YESNO

What is the current status of your accommodation request?* This field is required.

Approved and implemented

Approved but not yet implemented

Partially approved

Denied

Pending

Withdrawn

Other

If accommodations were implemented, how effective have they been?

Effective

Partially effective

Ineffective

Too early to determine

Has your agency considered or offered reassignment to another position?* This field is required.

Yes

Unsure

If the Accommodations Were Approved, Were They Effective?

YESNO

Please briefly describe the position considered or offered and the outcome

Do You Currently Telework?* This field is required.

Occasionally

Hybrid

Yes, I telework full-time

Have you received formal performance, attendance, or conduct documentation related to your medical condition?Examples include performance improvement plan, attendance counseling, written performance concerns, or formal restrictions on duties.

Yes

Unsure

Has your agency completed a formal assessment of reasonable accommodation or reassignment?

Yes

In progress

Unsure

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 and supporting documents you plan to submitCheck all that apply.

Functional Capacity Evaluation (FCE)

VA clinic notes

Private treating clinician notes

Imaging / lab reports

Operative reports

Neuropsychological testing

Mental health treatment records (if applicable)

Official Position Description (PD)

SF 3112C or other clinician documentation

Agency accommodation/reassignment documentation

OPM denial or reconsideration decision

Medical restrictions or work status documentation

Other

Approximate number of pages you plan 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 that a Level 0 preliminary medical assessment, if performed, does not include a comprehensive disability retirement medical opinion and does not guarantee that a favorable medical opinion can be supported.

I understand this is not advocacy, not legal advice, and does not guarantee approval of my federal disability retirement application.

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

What type of medical review are you seeking?* This field is required.

Level 0 Preliminary Medical Assessment: Our physician reviews selected relevant records to determine whether the available medical evidence appears sufficient to support a comprehensive disability retirement medical opinion.

Level 1 Focused Medical Narrative: A focused physician narrative addressing documented medical conditions, functional limitations, and occupational duties.

Level 2 Comprehensive Disability Retirement Medical Opinion: A detailed, evidence-based analysis of medical conditions, functional impairment, prognosis, and occupational requirements.

Supplemental Medical Opinion (existing clients only): Additional medical analysis or clarification of an opinion previously prepared by our physicians.

Not sure; please recommend the appropriate service

Other

What aee you hoping our physician can help clarify or explain in your disability retirement application?Optional

Signature* This field is required.

Date submitted* This field is required.(Today's date)

Date

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

DMS Federal Disability Retirement IMO Intake Form