CMS 95 Form – Fill Out and Use This PDF

CMS 95 Form PDF Details

The CMS 95 form is the official physician's statement required by the Illinois Department of Central Management Services. This document records an employee's medical condition during a disability leave of absence. Physicians, state employees, and HR administrators all use it to coordinate the leave approval process.

What the CMS 95 form covers

The form collects medical and administrative information across five main areas.

Diagnosis and treatment. The attending physician records the diagnosis, the dates of treatment, and how often the patient receives care. They also list any surgical procedures and state whether current treatment will change the patient's ability to perform work duties.

Patient progress. The physician checks boxes to show whether the patient has recovered, improved, stayed the same, or declined. The form also asks whether the patient is ambulatory, house-confined, or bed-confined, and whether the patient was hospitalized during the period covered.

Physical impairment class. This form uses a five-class rating system. Class I indicates slight limitation of functional capacity. Class V indicates severe limitation that prevents any productive work. The physician selects the class that best fits the patient's current condition and adds remarks as needed.

Extent of disability. This section records whether the patient is disabled from their regular occupation or from any occupation at all. The physician also provides an estimated date when the patient may be able to return to work, if applicable.

Physician certification. The attending physician prints their name, enters their professional degree, signs the form, and records the date of completion. Documents submitted without a physician signature will not be accepted for processing.

Who needs to file the CMS 95 form

Illinois state employees who apply for disability leave must have their attending physician complete this document. The employer then submits it to the Illinois Department of Central Management Services as part of the leave approval package. Late or incomplete forms can delay disability benefit payments, so confirm submission deadlines with your HR department before sending.

Depending on your situation, you may also need a FMLA leave form for federally protected medical leave or a leave of absence request form to formally document the absence with your employer. Once your physician clears you to return, a return-to-work release form may also be required to complete the process.