BASIC (09-08)

A. When to use form SSA-1709 (Request for Workers’ Compensation/Public Disability Benefit Information)

1. Use the SSA-1709 to verify WC/PDB payments from the agency or carrier responsible for the WC/PDB payment when the number holder (NH) is unable to provide the necessary verification.

   NOTE: It is permissible to obtain multiple SSA-1709s to be used for future development.

2. Some states and other entities require authorization to release information to SSA.

3. For pdf and eForm versions of the SSA-1709, see OS 15020.295.

B. Completing the SSA-1709

1. Complete the front page of the form.

2. Mail the form to the NH to obtain their signature as shown below and include a return addressed envelope.

3. The NH should sign below block 6.

4. Send original to the agency or carrier and retain a copy in the file.NOTE: On the back of the form SSA-1709, circle the NOTE at the top of Part II to expedite the response.

5. Prepare a diary to control return of the form.

6. Processing centers will follow the DIRCON guidelines in GN 01070.305 - GN 01070.330.

7. Field offices will follow GN 00301.050, if follow-up contact is necessary.

8. Fully document all follow-up contacts.

C. Receipt and review of the SSA-1709

The carrier can submit a copy of the compensation decision, payment record, court order, award letter, etc., which shows the payment data requested in lieu of or in addition to completing the form SSA-1709.

1. Review the form and any attachments carefully to ensure accurate and necessary information provided for computing offset.

   EXAMPLE: Carriers will sometimes show incomplete information in Part II, Item 7.a., of the form the initial WC rate, without showing the interim changes and carriers will sometimes show money amounts on a “when paid” basis instead of showing the period the payment was for. Carriers often incorrectly enter in Part II, Item 8.b.1. of the form the total amount of medical expenses paid on a WC claim instead of entering only the amount that was actually deducted from the lump sum payment. In this situation, verify that the amount shown was the actual amount deducted from the lump sum and not paid by the carrier.

2. See reminders for what is considered unacceptable proof in DI 52145.001E.

3. Reconcile any discrepancies by phone and document the call on a SSA-5002, Report of Contact.

4. Cancel any outstanding development control.

5. Process offset where applicable through MCS or ICF.

6. Fax the SSA-1709 to the electronic folder (EF) or Non-Disability Repository for Evidentiary Documents (NDRed). (See GN 00301.322.)