Follow the steps to successfully complete the MS PERS DSBL 5 form online.

1. Click the ‘Get Form’ button to access the MS PERS DSBL 5 form online and open it in your editor.
2. Begin filling out the Member Information section: Enter your first name, middle initial, last name, social security number, and birth date.
3. Move to the Treating Physician Information section: List the names of physicians who treated you for your claimed medical condition in the last five years. Provide their medical specialty, mailing address, city, state, zip code, phone number, frequency of visits, and the dates you were first and last seen. Include the reason for your visits or treatments.
4. If more than one physician treated you, attach an additional sheet with the same information for each additional physician.
5. Proceed to the Treating Facility Information section: List the facilities where you were treated for your claimed medical condition in the last five years. Provide the facility name, indicate the type of service (inpatient, outpatient, emergency), mailing address, city, state, zip code, admission date, discharge date, and the reason for the treatment, including any special testing like x-rays or MRIs.
6. If you received treatment at more than one facility, attach an additional sheet with the same information for each additional facility.
7. Complete the Applicant Certification: Review the statement regarding the accuracy of the information provided. Sign and date the form. If someone is signing on your behalf, attach the legal document proving their authority to do so.
8. Once you have filled out the form completely, save your changes. You can download the form, print it, or share it as needed.

Start filling out your MS PERS DSBL 5 form online today!