TN 11 (01-17)

Exhibit 1 - SSA-847-U3 (Social Security Administration Request for Case Action)

To view this form, go to SSA-847-U3.

Exhibit 2 - Form SSA-454-BK (Continuing Disability Review Report)

To view this form, go to SSA-454-BK.

Form SSA-454-BK (Continuing Disability Review Report) Completion Guidelines

For completion guidelines for the Form SSA-454-BK, see DI 13005.040.

Exhibit 3 - Developmental guidelines

There are guidelines for individual MINE impairments, groups of impairments and situations in which there may be documentation deficiencies or contradictory situations, or a greater possibility of medical improvement. The disability determination services (DDS) will follow specific guidelines in making appropriate judgments about the level of documentation required and the questions to ask treating sources. For additional information on the development guidelines involving MINE or MINE-equivalent impairments, see DI 28040.130.

Exhibit 4 - Suggested language for request that individual return the Form SSA-SSA-827

We are sending you forms, “Authorization to Disclose Information to the Social Security Administration” (SSA-827), to sign and return to us. We must have your signature (or your appointed representative's) on this form before we can make a decision on your claim. This form allows doctors, hospitals, clinics, and other sources to give us information about your condition. Use the enclosed self-addressed envelope to return the forms.

Enclosures:
SSA-827
Mailing Envelope