AGENCY LETTERHEAD
Date: [Fill-in]
Case ID: [Fill-in]
Addressee Name
Address Line 1
Address Line 2
City, State, ZIP Code
CALL IN LETTER
We are the office that makes disability decisions for the Social Security Administration.
It is very important that we speak to you by [10 calendar days] to confirm your upcoming appointment(s).
Appointment Information
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Provider Information
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Date and Time
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Type of Appointment*
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CE provider name
CE provider address
CE provider phone number (if required by state)
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Weekday
Appointment date
Appointment time with time zone
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CE procedure specialty type(s)
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*The provider may decide not to do some of the tests we ordered or that other tests
are needed.
Travel to and from the appointment is your responsibility. If there is a problem keeping
the appointment(s), please call our office at [DDS phone number].
If you do not respond by [10 calendar days], we may cancel your appointment(s) and
we may decide your case based on the evidence already in file. This means that we
could find you are not disabled based on our rules or that your disability has ended
if you are already receiving benefits.
Please call the phone number(s) shown below Monday - Friday between [DDS office open]
and [DDS office close]. When you call or leave a message, please provide the Case
ID: [case ID number], your name, and a call back number.
Thank you for your cooperation,
[Name]
[Phone Number]
[Fax Number]
Enclosures:
Multi-Language Insert (if enclosed)