TN 14 (12-04)

A. Introduction

Some major medical sources treat numerous patients from other parts of the country or have many ex-patients now living out of the region.

The resident FO is required to document the files with special information when the sources listed below have treated the claimants. This information enables the DDS to process the requests for medical evidence.

At the RO's discretion, the FO may be authorized to prepare and release requests to these institutions. Addresses are provided for this purpose.

B. Procedure - general

1. Providing information for DDS use

Include the specific information on the applicable disability report form.

2. FO authorized to send request

If the FO is authorized to prepare and release a request to the medical institution:

1. Always send a recently completed, signed, and dated SSA-827.

2. Ensure that the specified information is on this SSA-827.

3. Advising RO of additional special sources

1. Inform the Regional Office Center for Disability Programs of other medical sources that appear to fall into this category.

2. Estimate or establish by inquiry the number of SSA requests received by this particular source in a given period.

C. Procedure - contacting hospitals

1. Cook County Hospital and John H. Stroger, Jr., Hospital of Cook County

1. Send an SSA-562-U3 to:

   Bureau of Disability Determination Services
   Attn: Medical Information Unit
   P.O. Box 19250
   Springfield, IL 62794-9250

2. Include:

   • Admission dates

     NOTE: Show at least the year of admission. Make note of admissions with unknown dates.

   • Discharge dates

     NOTE: If the claimant is currently hospitalized, the hospital will not furnish a report.

   • Inpatient or outpatient status

   • Date of birth

   • Name and address at the time of admission (if different from the present)

   • Hospital unit name, if known

   • Patient’s hospital unit number

     NOTE: The 6-digit hospital number (followed by a letter) is on any hospital identification card issued after January 1, 1969.

3. After 30 days, follow up by telephone contact with the Medical Information Unit at (217) 785-5677.

   NOTE: Cook County Hospital, which provided in-patient care only, is now closed. These records are located in the same Medical Records Department that now services the new John H. Stroger, Jr., Hospital, which is in the same general location in Chicago. Please send all requests for records from either facility to the Medical Information Unit in the Illinois DDS.

2. Duke University Medical Center

1. Send a standard request letter to:

   Duke University Medical Center
   Medical Records Release
   P.O. Box 3016
   Durham, NC 27710

2. Include:

   • Patient's full name

   • Date of birth

   • Parents' names

   • Dates of treatment

   • History number from the patient's hospital/clinic ID card.

3. Be sure the SSA-827 is dated within 90 days of receipt by Duke.

NOTE: If signed by someone other than the patient, explain why in the request.

3. Fantus Health Center

1. Send an SSA-562-U3 to:

   Bureau of Disability Determination Services
   Attn: Medical Information Unit
   P.O. Box 19250
   Springfield, IL 62794-9250

2. Include:

   • Claimant’s name and address

   • Date of birth

   • Date of first clinic visit

   • Date of last clinic visit (include the word “outpatient”)

   • Name and address at time of last visit (if different from present)

   • Clinic or unit number (e.g., clinic number 70-62498; unit number - 421377)

3. After 30 days, follow up by telephone contact with the Medical Information Unit at (217) 785-5677.

NOTE: Send all requests for records from Fantus Health Center (Chicago) to the Medical Information Unit in the Illinois DDS.

4. Grady Memorial Hospital – Atlanta, Georgia

Send out-of-State requests using a standard request letter to:

5. Hennepin County Medical Center:

1. Send a standard request letter to:

   Simtek
   Medical Records Section
   Hennepin County Medical Center
   701 Park Avenue South
   Minneapolis, MN 55415

2. Include:

   • Patient's full name

   • Dates of treatment

   • Hospital admission number

   • Alleged impairment.

6. Johns Hopkins Hospital

1. Send a standard request letter to:

   Johns Hopkins Hospital
   Medical Information Section
   Department of Medical Records and Statistics
   600 N. Wolfe Street
   Baltimore, MD 21287-1015

2. Include the following information:

   • Full name of patient

   • Hospital number

   • Date of birth

   • Sex

   • Attending physician's name

   • Date(s) of hospitalization or treatment.

7. Massachusetts General Hospital

1. Send a standard request letter to:

   Correspondence Department
   Massachusetts General Hospital
   121 Inner Belt Road
   Somerville, MA 02143-4453

2. Include the hospital record number (also known as patient identification number and the patient unit number) located on the blue patient card also referred to as the ID, hospital card, or plastic card. If unavailable, also include:

   • Full name and address at time of admission (if different from present)

   • Date of birth

   • Dates of admission and discharge

   • Name of attending physician.

NOTE: For information about impairments of the eye, ear, nose, and throat, send the request to the Massachusetts Eye and Ear Infirmary.

8. Massachusetts Eye and Ear Infirmary

1. Send a standard request letter to:

   Massachusetts Eye and Ear Infirmary
   Attn: Medical Records Correspondence Office
   243 Charles Street
   Boston, MA 02114

2. Include:

   • Hospital record number. If it is unknown, provide the billing account number, if it is available.

   • Full name and address at time of admission (if different from present)

   • Date of birth

   • Dates of admission and discharge

   • Name of attending physician.

3. If the claimant has been examined or treated in both, the hospital and the infirmary, send two separate requests.

9. Mayo Clinic

1. Send a standard request letter to:

   Mayo Foundation
   200 1st Street SW
   Attention: 201 Building TO-02-20
   Rochester, MN 55905

2. Include:

   • Name and address of requesting office

   • Date of request

   • Claimant's name and address

   • Mayo Clinic number

   • Alleged onset date

   • Date of birth

   • Date of most recent examination

   • Social Security number

   • Alleged impairment(s)

   • All remaining medical entries to include specific dates, as pertinent

   • FO contact and telephone number.

3. FAX any MER request, if applicable, to (507) 266-0447. Faxes may be sent in care of Lisa or Carey.

4. Send all requests for medical records from Rochester Methodist Hospital and St. Mary's Hospital to the address in DI 11005.060C.9.a. Only one form is needed to request medical evidence from Mayo. Only one form is necessary if the claimant was seen at Mayo, St. Mary's and Rochester. The three facilities are considered the same for MER purposes. There is only one set of medical records for these facilities.

5. Send one request only to the address in DI 11005.060C.9.a. if the claimant has listed both the Mayo Clinic and a separate medical source (e.g., a physician) at the Mayo Clinic as MER sources on the SSA-3368-BK or SSA-3820-BK.

6. MER requests are processed by SourceCorp. If any problems are encountered with a request, their on-site supervisor is Mary Connor, (507) 284-2750.

10. Puerto Rico Medical Center

1. Send a standard request letter to:

   Administración de Servicios Médicos de Puerto Rico
   P.O. Box 2129
   San Juan, PR 00922-2129
   Atención: Hospital _____________________

2. b. Because this medical center is a complex of hospitals such as the University Hospital, Oncologic Hospital, Children’s Hospital, San Juan Municipal Hospital, Industrial Hospital, Centro Cardiovascular del Caribe, Psychiatric Hospital, include:

   • Claimant's complete name including both surnames (e.g., Ortega-Gasset)

   • Date of birth

   • Place of birth

   • Social Security number

   • Medical record number (usually 8 or 9 digits)

   • Division where treated (e.g., mental, oncological, etc.)

   • Type of treatment (inpatient or outpatient)

   • Dates of treatment

   • Allegations

   • Claimant's address at time of treatment while living in Puerto Rico.

   • Onset date

   • Claimant's father's name and mother's maiden name.

11. Saint Elizabeth's Hospital

1. Send a standard request letter to:

   Department of Mental Health
   Medical Records Section
   St. Elizabeth's Hospital
   2700 Martin Luther King, Jr. Avenue, S.E.
   Washington, DC 20032

   NOTE: To followup on requests, call (202) 442-8516

2. Include:

   • Claimant's name and aliases

   • Social Security number

   • Date of birth

   • Inpatient treatment dates

   • Outpatient treatment dates

   • Alleged onset date

   • Specific testing

   • Patient number, if available

   • Name of treatment team

   • Level of claim being filed, such as title II CDR, title XVI initial claim

   • Any other available identifying information.

   NOTE: The hospital will request records prior to 1982 (in the FRC, Suitland, MD). The average response time is 60-90 days.

12. The Ruth M. Rothstein CORE Center - Chicago

1. Send an SSA-562-U3 to:

   Bureau of Disability Determination Services
   Attn: Medical Information Unit
   P.O. Box 19250
   Springfield, IL 62794-9250

2. Include:

   • Claimant’s name and address

   • Date of birth

   • Date of first clinic visit

   • Date of last clinic visit (include the word “outpatient”)

   • Name and address at time of last visit (if different from present)

   • Clinic or unit number, if available, (e.g., clinic number 70-62498; unit number - 421377).

3. After 30 days, follow up by telephone contact with the Medical Information Unit at (217) 785-5677.

D. Procedure - Federal Bureau of Prisons (FBOP)

For procedures to develop evidence from the FBOP, see DI 22505.026.