HEAL Form 539

U.S. DEPARTMENT OF EDUCATION
Federal Student Aid

OMB Control No. 1845-0124
Expiration Date:Form Under
Review

PHYSICIAN'S CERTIFICATION OF BORROWER'S TOTAL AND PERMANENT DISABILITY
PRA Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. The valid OMB control number for this information collection is 1845-0124. Public reporting burden for this
collection of information is estimated to average 5 minutes for the borrower, 10 minutes for the holder/servicer, and 30 minutes for the physician per
response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit (the Consolidated Appropriations Act,
2014). If you have comment or concerns regarding the status of your individual submission of this form, please contact the HEAL Program , U.S.
Department of Education, 830 First Street NE, Washington, DC 20202 directly. [Note: Please do not return the completed form to this address.]
WARNING: ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT OR MISREPRESENTATION ON THIS FORM MAY BE SUBJECT TO FINE OR IMPRISONMENT
UNDER SECTION 1001 OF THE UNITED STATES CRIMINAL CODE.

GENERAL INSTRUCTIONS

This form is used for obtaining a physician's certification of a borrower’s permanent and total disability for the purpose of cancellation of the borrower’s obligation to repay his or her student
loan(s) obtained under the Health Education Assistance Loan (HEAL) program.

DEFINITION OF TOTAL AND PERMANENT DISABILITY - Physician must certify that the borrower is unable to engage in any substantial gainful activity by reason of a
medically determinable physical or mental impairment that (1) can be expected to result in death; (2) has lasted for a continuous period of at least 60 months; or (3) can be
expected to last for a continuous period of at least 60 months. Substantial gainful activity means a level of work performed for pay or profit that involves doing significant
physical or mental activities or a combination of both. If the borrower is able to engage in any substantial gainful activity in any field of work, physician must not certify total
and permanent disability.
It should be noted that the standard for determining disability for cancellation of the borrower's loan obligation may be different from standards used under other public and private
programs in connection with occupational disability or eligibility for social service benefits.

INSTRUCTIONS FOR BORROWER
1.

2.
3.

INSTRUCTIONS FOR PHYSICIAN

Complete Section I and sign the form. A representative of the
borrower may complete this section and sign the form on the
borrower's behalf if the borrower is unable to do this because of his or
her disability.
Have Section II of the form completed and signed by a doctor of
medicine or doctor of osteopathy.
Return a completed copy(s) of this form to each holder/servicer which
has made a loan to you under the Health Education Assistance Loan
(HEAL) program.

PLEASE NOTE: Complete this form only If you are a doctor of medicine or a doctor
of osteopathy legally authorized to practice in your state
1.

2.

Complete Section II and sign the certification only If the borrower's condition
meets the above definition of total and permanent disability. Please make
your report complete, as to the nature, duration and severity of the borrower's
present and future impairment. You may attach additional pages if necessary.
Return this form to the borrower listed in Section I.

Before sending to your loan holder/servicer, please, make sure
that Section II (Certification of Borrower's Total and Permanent
Disability) has been completed. If you are a disabled Veteran,
please contact your servicer prior to submission.

Section I – TO BE COMPLETED BY BORROWER OR BORROWER’S REPRESENTATIVE
(See instructions above. See Privacy Act notice on reverse side.)
1. NAME OF BORROWER (Last)

(First)

(MI)

2. BORROWER’S SOCIAL SECURITY NUMBER

3. NAME AND ADDRESS OF BORROWER OR BORROWER’S REPRESENTATIVE (Print or type)

4. AGE OF BORROWER
5. DATE OF BIRTH

MM

DD

YYYY

_________/__________/___________

MM

DD

YYYY

________/_________/_________
8. COURSE OF STUDY

7. GRADUATION DATE

6. DATE ENTERED HEAL SCHOOL

MM

DD

YYYY

_________/_________/__________

9. EMPLOYMENT HISTORY (since separation from school)

CONSENT FOR RELEASE OF INFORMATION – I authorize any physician, hospital or other institution having records pertaining to the disability for

which I am requesting discharge of my loan(s) to make information from such records available to the Department of Education and to the
holder/servicer of my loan(s). I authorize the Department of Education to contact my physician(s) to receive my medical records and discuss
my medical condition.
SIGNATURE OF BORROWER OR REPRESENTATIVE

DATE

MM

DD

YYYY

____________/___________/_____________

HEAL 539 (Front)

See Back for Sections II and III

SECTION II – TO BE COMPLETED BY CERTIFYING PHYSICIAN
1.

WHEN DID THE BORROWER’S PRESENT ILLNESS OR INJURY START?
MM

DD

2.
WHEN DID THE BORROWER BECOME UNABLE TO ENGAGE IN ANY SUBSTANTIAL
GAINFUL ACTIVITY?
MM

YY

_______/_________/_________

DD

YY

_______/_________/_________

3.

DIAGNOSIS OF BORROWER’S PRESENT MEDICAL CONDITION.

4.

NATURE OF ONSET

5.

CURRENT MEDICATIONS

6.

REHABILITATION PLANS (Include any treatment which has not been accepted by the Borrower)

7.

BORROWER IS

□ AMBULATORY; □ BED CONFINED; □ HOUSE CONFINED; □ HOSPITAL CONFINED; □ OTHER______________________________________________

8. PROGNOSIS – IS THE APPLICANT'S IMPAIRMENT EXPECTED TO RESULT IN DEATH?

□ YES □

NO IF “YES”, SKIP TO ITEM 9. IF "NO" CONTINUE TO ITEM 8A.

8A. - HAS THE APPLICANT'S IMPAIRMENT LASTED OR IS IT EXPECTED TO LAST FOR A CONTINUOUS PERIOD OF AT LEAST 60 MONTHS? □ YES □ NO IF “YES”,
CONTINUE TO ITEM 9. IF "NO" DO NOT COMPLETE THIS APPLICATION.
9.

PHYSICIAN CERTIFICATION OF BORROWER’S TOTAL AND PERMANENT DISABILITY

I certify that in my best professional judgment (borrower’s name____________________________________________________________________________________________) is unable to
engage in any substantial gainful activity by reason of any medically-determinable physical or mental impairment that can be expected to result in death; has lasted for a continuous period of not
less than 60 months; or that can be expected to last for a continuous period of not less than 60 months.
I am legally authorized to practice in the State of ____________________________. Professional License No. ____________________________
10.

NAME & ADDRESS OF PHYSICIAN (Print or type)

11.

DATE

MM

DD

YY

_______/_________/_________
12.

SIGNATURE OF PHYSICIAN (M.D. OR D.O.)

SECTION III – TO BE COMPLETED BY LOAN HOLDER/SERVICER
(Borrower and Physician leave blank)
1.

LOAN HOLDER/SERVICER NAME

3. TOTAL AMOUNT OF UNPAID BALANCE
$_______________________________________

Privacy Act Notice

2. LOAN HOLDER/SERVICER ADDRESS

4. DATE PREPARED BY HOLDER/SERVICER

MM

DD

YYYY

__________/_________/___________

– The Privacy Act of 1974 (5 U.S. C. 522a) requires that an agency provide the following notice to each individual whom it asks to supply information.

1.
The authority for collecting the information requested on this form is found in 34 CFR 681.39 (b) and 685.213 and the Consolidated Appropriations Act, 2014.
2.
The principal purposes of this information are to verify the identity of the borrower; eligibility for loan cancellation; and in the event it is necessary to locate the
borrower’s representative or certifying physician. The SSN is used as a loan account number (identifier) in order to accurately record necessary information.
3.
The routine uses of this information include its disclosure to Federal, State or local agencies, to guarantee agencies, to educational and financial institutions
and to agency contractors for the purpose of: verifying the identity of the borrower and the borrower’s physician: determining the borrower’s eligibility for loan cancellation;
investigating possible fraud and verifying compliance with program regulations. Failure to provide the requested information may cause the Department of Education to
deny the borrower’s request for loan cancellation.
4.
This information is necessary to process requests for loan cancellation.
HEAL 539 (BACK)