TN 17 (12-11)

                                                                                                        ****BARCODE****

                                                           AGENCY

                                                        LETTERHEAD

                                                                                                         Date: _______________

                                                                                                        Claim ID: ___________

Addressee Name

Address Line 1

Address Line 2

City, State, ZIP Code

Claimant: [Fill-in]

DOB: xx/xx/xxxx

We are the office that makes disability determinations for Social Security. [First Name] [Last Name] is applying for or is receiving disability benefits due to the following conditions: [List Conditions]

Please provide medical evidence including the following information: medical history, clinical findings, laboratory findings, treatment prescribed and the response, diagnosis, and prognosis.

Please send the information requested below, covering the period of [Fill-in date] to [Fill-in date], to help us evaluate this claim.

• [Fill-in] (e.g., history, diagnosis/prognosis, most recent mental status exam, etc.)

• [Fill-in]

We are enclosing a signed HIPAA compliant authorization (SSA-827) for the release of medical records and information.

[Optional canned text for claims involving mental impairments]

Please provide a statement based on your findings. Your statement should express your opinion about your patient’s ability to do work-related mental activities despite the limitations imposed by his/her mental condition(s). These activities include: understanding, carrying out and remembering instructions, and responding appropriately to supervision, coworkers, and work pressures.

[Optional canned text for claims involving physical impairments]

Please provide a statement based on your findings. Your statement should express your opinion about your patient’s ability to do work-related physical activities despite the limitations imposed by his or her medical condition(s). These activities include sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.

[Optional canned text for a claim for a child]

Please provide a statement based on your findings. Your statement should express your opinion about your patient’s abilities and limitations compared with children of the same age without medical conditions. Consider areas such as, but not limited to, age-appropriate learning, attention, interaction with other people, motor functioning, and behavior and self-care. Please also comment on how this child’s medical condition(s) and associated treatments, including the frequency of treatment, affect his or her overall functioning.

Submitting Records: Refer to instructions on the bar-coded cover page.

Payment Information: We will pay you for the evidence you provide. See the attached invoice for instructions. To receive payment, you must complete the attached invoice and submit it with the requested records and statements within [Fill-in#] days of the date of this letter.

[Optional canned text]

We do not pay any State or Federal facility. If you are in such a facility, you will not find a voucher in this request.

For billing questions or inquiries please call x-xxx-xxx-xxxx.

Other Information: Please indicate if you would be willing to do an examination, test, or both at our expense if we later determine that we need more medical information. If you do not respond, we will assume that you do not wish to conduct such an examination of this patient.

______ Yes, I am interested. ________ No, I am not interested.

If you have any other questions, please contact [Mr./Ms.] [Disability Examiner’s name] at xxx-xxx-xxxx.

If there are no records for this patient please check here ___________

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 answer these questions 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.

Enclosures:

SSA-5000 (Privacy Act Statement)

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