BASIC (03-86)

The SSA-847-U3 will be used by the examiner to request the DDS to obtain MER and/or a CE for the foreign agencies. The examiner will complete the following items:

• TOE Code “520”

  Request Code “1-P-48”

  Date

  TO: (Name of DDS)

  Social Security Number

  Name of Disabled Individual

  Under “A. Action Requested”--check No. 4

The “Remarks” section will be headed with the caption, “Totalization Claim--Medical Development Request from (Name of Country)--No Determination Necessary” (DI 23550.001). Use of this heading is mandatory and must be entered on the SSA-847-U3 exactly as stated here. When preparing the medical portion of the request, the examiner may adapt the guide language in A. and B. below to suit the situation.

1. The claimant, who resides at     (Address)     ,    (Phone No.)   , has filed for disability benefits with the   (Name of Country)   Social Security agency. We have agreed to assist that agency in their medical development. To obtain the evidence requested by that agency, please ask the following treating sources to furnish a report of claimant's medical history, physical and laboratory findings, clinical course, therapy, and response to treatment. (Optional) We are particularly interested in the claimant's   (Name of body systems(s))   status.

2. The claimant, who resides at     (Address)     ,    (Phone No.)   , has filed for disability benefits with the   (Name of Country)   Social Security agency. We have agreed to assist that agency in their medical development. To obtain the evidence requested by that agency, please schedule the following tests and examinations for the claimant.

   Inform the DDS if background medical evidence is attached to the SSA-847-U3, or that we have no available medical evidence of record to send with our request.

   Each request must be concluded with a reminder to the DDS to enclose a statement of charges for the medical evidence obtained. This statement is also a mandatory item, and the examiner must use the language below.

   • “Submit an itemized statement of charges when you return the medical reports. If you have any questions, please contact a disability examiner at the phone number shown below. Please return all reports and statements in an envelope, without a folder jacket, to the Social Security Administration, INTPSC, Totalization, P.O. Box 17049, Baltimore, Md. 21235, with the remark “Associate with totalization folder and forward to FDE.” Please remember to show the claimant's SSN on all correspondence. Thank you. (Examiner's name, FTS number, and Comm. number.)”

   See DI 43535.035, Exhibit 6, for a sample SSA-847-U3 to be used when requesting a CE.