Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the name of the person examined in the designated field. Ensure that the name is spelled correctly for verification purposes.
3. Provide the social security number of the individual seeking benefits, which is crucial for identification.
4. Enter the complete address of the individual, including street address, city, state, and zip code. Make sure all details are accurate.
5. For question 1, indicate whether the individual qualifies as having a disability. Select ‘YES’ or ‘NO’ based on the individual’s circumstances.
6. Detail the nature of the disability in the provided text box. Be concise and clear while describing the condition.
7. State when the condition was originally diagnosed, providing an accurate date to ensure proper processing.
8. In the certification section, the physician's name is required. Ensure that the physician personally examines the individual.
9. The physician must sign the document, affirming the accuracy of the information. They should also print or type their name below the signature.
10. Fill in the business address of the physician, including street, city, state, and zip code.
11. Lastly, the physician should provide their phone number and the date when the form is completed.
12. Once all fields are completed, save changes, download the document, and print or share the completed form as needed.

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