NL: Notices, Letters and Paragraphs
TN 17 (12-11)
A. Model 1 CE appointment notice
AGENCY
LETTERHEAD
Date: _______________
Case ID: [Fill-in]
Addressee Name
Address Line 1
Address Line 2
City, State, ZIP Code
MEDICAL APPOINTMENT NOTICE
Dear [First Name] [Last name],
We are the office that makes decisions for Social Security. We made a medical appointment for you because we need more information about your medical condition for your Social Security disability claim. We will pay for this appointment.
Your Medical Appointment Information
|
Name and Address |
Phone Number |
Date and Time |
Type of Appointment* |
*The medical evaluator may decide not to do some of the tests we ordered or that other tests are needed.
Please arrive at your appointment 15 minutes early. If you are late, the medical evaluator may choose not to see you.
What you should bring to the appointment
Bring this letter and personal identification (e.g., U.S. State-issued driver’s license or non-driver identity card, U.S. passport, U.S. military ID, student or school ID). Bring any medications that you take in their original containers. Also, bring your hearing aids, eyeglasses, contact lenses, canes, or other medical aids if you use them.
What you should do next
Confirm that you will attend your appointment. Please complete the enclosed response form and mail it in the pre-addressed envelope provided. (Use the second sentence, only if you enclose a response form.) You should respond to our office within ten days of the date on this letter.
Let us know if you cannot attend your appointment, as scheduled. Please call our office immediately if you cannot attend your appointment for any reason. If you cannot attend your scheduled appointment, and you would like us to reschedule, you must give us a good reason.
If you have any questions or need assistance for the appointment
Contact us if you need help to pay for travel expenses to the appointment. We will only consider payment of these costs if you ask us promptly. Normally, we reimburse approved expenses after you attend the appointment. However, we will consider your request for advance payment if you show us that the request is reasonable and necessary.
Also, call us if you need to request special arrangements for this medical evaluation because you have a health issue that makes traveling difficult.
Let us know if you need a foreign language interpreter, a sign language interpreter, or other assistance to communicate effectively with the medical evaluator. We will arrange for interpreter services at no cost to you.
If you want a copy of the report sent to your doctor
If you want a copy of the report from this medical evaluation sent to your doctor, please provide his or her full name and address. Please complete the enclosed authorization form. (Use this statement only if you enclose an authorization form.)
If you miss the scheduled appointment
If you do not attend your appointment, we may make a decision based on the evidence we already have in your file. We may find that you are not eligible or no longer eligible for disability benefits. Please read the enclosed leaflet that explains more about the consultative examination and your responsibility for attending.
If you have any questions about this letter or need to contact us about the appointment, call Monday-Friday between 8:00 a.m. and 4:00 p.m. at the phone number below.
Thank you for your cooperation,
(NAME)__________________
(TITLE) __________________
PHONE NUMBER [Fill-in]
TTY/TRS [Fill-in]
Enclosures:
SSA Publication No. 05-10087 (A Special Examination Is Needed for Your Disability Claim)
Consultative Examination appointment confirmation form (List if enclosed.)
Authorization form (List if enclosed.)
SSA-5000 (Privacy Act Statement) (Enclose and list if you enclose the CE appointment confirmation form or authorization form.)
B. Model 2 CE appointment confirmation form
AGENCY
LETTERHEAD
Date: _______________
Case ID: [Fill-in]
Addressee Name
Address Line 1
Address Line 2
City, State, ZIP Code
Dear [First Name] [Last name],
Please check the correct box to let us know if you will attend your appointment on [Fill-in mm/dd/yyyy].
[ ] I will attend the medical appointment scheduled for my Social Security claim:
[ ] I cannot attend the medical appointment because
__________________________________________________________________.
Appointment Information
Medical Evaluator [Fill-in]
Address [Fill-in]
Date [Fill-in]
Time [Fill-in]
IMPORTANT: Please sign, date, and mail this form as soon as possible using the pre-addressed envelope provided. If you cannot attend the scheduled appointment or require additional assistance to attend, notify us immediately at (XXX) XXX-XXXX.
__________________ ______________________
(Your Signature) (Date)
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to provide this information unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0555. We estimate that it will take between 5 to 30 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
C. Model 3 Authorization form for release of a copy of the CE report to the claimant’s doctor
Case ID: [Fill-in]
I, [First Name] [Last name], authorize the Social Security Administration to send a duplicate of the consultative examination report by [Fill-in name of the medical evaluator], to:
Your Doctor’s Name: __________________
Address Line 1: __________________
Address Line 2: __________________
City, State, ZIP code: __________________
An individual may revoke his/her consent at any time with a written request.
__________________ ______________________
(Your Signature) (Date)
__________________ _______________________
(Your Address) (Your Telephone Number)
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to provide this information unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0555. We estimate that it will take between 5 to 30 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
D. References
DI 22510.016 Consultative Examination (CE) Appointment Special Scheduling Procedures
DI 22510.017 Consultative Examination (CE) Appointment Notice
DI 22510.019 Consultative Examination (CE) Appointment Notice Follow up and Reminder
DI 22510.065 Sending the CE Report to the Claimant’s Treating Source
DI 23007.009 Refusal to Attend a Consultative Examination (CE) Appointment
DI 23007.010 Failure to Attend a Consultative Examination (CE) Appointment
GN 03360.015 Privacy Act Administration Collecting Personal Information