Residual disability evaluation request – Form 14-08

• Pay attention to patients in consultation who request the disability pension, to corroborate the assessment of the treating physician.
• Assist in consultation with patients who request reconsideration of their status.
• Calculation of the percentage of disability based on the scale.
• Make the reports on the Disability Assessment.
• Make a detailed report on the number of patients who have been evaluated for disability and their respective percentage to deliver it to the Rehabilitation department.
• Preserve all records of the disabled attended

• Applicant Type: You must make your selection with «X» indicating the type of Employer, Employer or Natural person/physician applicant.
• Date of elaboration: Day month and year the form is issued.
• Patient First Name and Middle Initial and Last Name and Middle Initial
• Identity card: Indicate with «X» if you are Venezuelan or foreigner, and enter all the digits of your ID.
• Date of Birth of the patient.
• Age: Written in numbers.
• Sex: mark with “X” if it is female or male.
• Patient Address: It must be placed clearly and specifically.
• Patient Phone Number: Nlocal number
• Control number registration of applications issued by the Employer or Employer.
• Name of Employer or Company Name: Write the name of the Employer or Company Name, where the insured works.
• Employer Number of Employer or Employer assigned by the IVSS.
• Phone number: indicate the local telephone number of the Employer or Employer for which the insured works.
• Seniority in the Company or Institute: Place in number the years, months or days that the insured has working for the Company or Institution.
• Occupation: Position or function performed by the insured in their current job.
• If you are a Public Employee, Total Seniority Recognized as a Public Employee: Indicate in numbers the total number of years you have worked for the public administration.
• Type of Request or Other Observations: write specifically the type of request you wish to process or any observations regarding the request.
• Employer or Legal Representative: Write the name and surname, the identity card, signature and seal, of the person responsible for the company in charge of the procedures and applications before the Social Security.
• Applicant: Write the name and surname, the identity card and signature of the Applicant of the procedure.

• Control number that the Assistance Center records.
• Date of elaboration.
• Issuing Assistance Center: indicate clearly and legibly the name, denomination or company name of the public or private assistance center where the request was issued.
• Phone number of the care center where the form was prepared.
• Name and Surname of the Treating Physician requesting Evaluation.
• Specialty of the treating physician.
• Medical: Mark with an X (X) the type of facility where the treating physician works.
• Current Rest Start Date: Indicate in numbers the day, month and year in which the current disability began.
• Date of admission: Indicate in numbers the day, month and year that the patient began to be treated for the pathology described in the form.
• Egress date: Indicate by means of two (2) digits the day, month and year of the same date of preparation of the Residual Disability Evaluation Request Form (F: 14-08).
• Cause of the Injury (Etiology, indicating whether it is illness or accident) in case of occupational origin, attach INPSASEL Certificate: Mark with an X (X) the cause of the lesion for which the patient is being evaluated.
• Diagnosis(s) (if more space is required, attach Medical Report): write the diagnosis or diagnoses that effectively lead to requesting the evaluation of the disability for work.
• Treatment (Summary) in case of immediate surgical indication, indicate the probable date of the intervention (if more space is required, attach a Medical Report): You must write a summary of the treatment to which the patient must undergo.
• Evolution (Summary) (if more space is required, attach Medical Report): Summary of the patient’s evolution.
• Description of Residual Disability (Current Status) summary (if more space is required, attach Medical Report): detail the functions you have lost and, according to the treating physician, that limit you from carrying out your work activities.
• Attending Physician: affix signature, MPSS code and stamp of the doctor in charge of the medical evaluation to the patient.
• Director or Chief Medical Officer of the Issuing Center (Public or Private): indicate name and surname, identity card number and signature of the Director of the Assistance Center or Chief Medical Officer (if necessary) and affix the seal of the Assistance Center.

• Control number from the records of the Administrative Office.
• Date of elaboration: of the Residual Disability Evaluation Request Form (F: 14-08), by the Administrative Office.
• Administrative office name that receives the request for disability evaluation.
• Phone number the administrative office where the form was made.
• The undersigned Head of the Administrative Office, requests a medical evaluation of the citizen who is identified below, for the application of the regulations in force in: Mark with an X (X) the type of contingency to which the applicant wishes to accept.
• Receiving Official: Enter the name, surname, identity card number, signature and seal of the public servant responsible for receiving and preparing the form.
• Head of the Administrative Office: indicate name and surname, resolution number, signature and seal of the Administrative Office.

• Control number with which the Evaluation Commission counts the number of forms issued by said center.
• Date of elaboration: Day, month and year in which the form is issued.
• Name of the Authorized IVSS Commission or Sub-Commission: which leads the evaluation of the cases.
• Phone number: Indicate the local telephone number where the Evaluation Commission or Sub-Commission resides.
• Diagnosis of residual disability: The specific evaluating committee or sub-committee for work disability in order of importance.
• Observations: write of concretely if there is any observation regarding the application.
• Percentage Loss of Ability to Work: indicate the percentage in numbers and letters at which the evaluation commission or sub-commission has concluded.

Next, indicate the percentage in numbers and letters of the disability by common origin and occupational origin.

• Occupational Origin or Aggravated by Work, according to the INPSASEL Certificate: write the DIRESAT certificate number and the date it was certified.
• Authorized Member of the Commission or Sub-Commission: Write name, surname, identity card number, MPPS registration number, signature and seal.
• President of the Commission or Sub-Commission: Write name, surname, identity card number, MPPS registration number, signature and seal.

• Residual Disability Assessment Request, Form 14-08 (issued by the treating specialist doctor corresponding to the diagnosis or diagnoses) in ORIGINAL and two (2) carbon copies.
• Copy of the Enlarged and Legible Identity Card.
• Original and two (2) carbon copies of Proof of Work for the IVSS Form 14-100 (issued by the Human Resources Department of the Institution of affiliation).
• Original and Copies of the Clinical and Paraclinical Report related to the Pathology (s).
• Official Letter of Request for Evaluation of the Affiliation Institution mentioning the Article 9 and/or 13 of the IVSS Law Or to Article 14 of the Law of the Statute on the Retirement and Pension Regime of Officials or Employees of the National Public Administration.
• Individual Account (through the Internet through the page www.ivss.gov.ve).

• personal: Despite the fact that you have been diagnosed with a disability, it is possible that you remain working in the same company where you were before the diagnosis, holding another position, thus being able to supplement your income with that of the disability pension.
• State: They are those granted by the state such as socialist mission cards
• Transportation: In some public transport services considerations are taken with disabled people and they do not pay the ticket.