The above process is for initial claims only. Handle reconsiderations filed by residents
of Mexico as follows:
-
•
Obtain the usual reconsideration forms and send via express and follow the mailing
instructions shown in DI DAL11010.540B.6.a. The FO will not initiate any medical development unless contacted by OIO to do so.
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•
Folder movement will be made to V22.
Exhibit 1a
Request to Medical Source for Medical Evidence of Record (MER)
(English Version)
(1) Patient: (4)
SSN: (5)
DOB: (6)
Sex: (7)
Patient/Clinic No.: (8)
______________ (2) _______________
_____________________________
_____________________________
Dear (3) :
Your patient has applied for disability benefits through the Social Security Administration.
The Office of International Operations, Baltimore, Maryland, is responsible for determining
whether the claimant is eligible for benefits. We are assisting the claimant in obtaining
available medical evidence.
Disability is alleged because of (9) .
This is not a request that studies be performed if they have not been performed already.
Please furnish a narrative report and/or copies of your records for the period (10) to (11) , to include the following: __________(12)_________________________________________
_____________________________
We would also like to have a statement, based on your medical findings, of the claimant's
ability to perform work-related physical activities such as sitting, standing, walking,
lifting, carrying, handling objects, hearing, speaking, and traveling. When there
is a mental impairment, please indicate your opinion regarding understanding and memory,
sustained concentration and persistence, social interaction and adaptation.
If there is a charge for this service, please enclose an itemized statement with the
records. The Social Security Administration is authorized to pay up to $18.00 for
copies of medical records and/or narrative report.
Thank you for your prompt attention to this request. If you have any questions, please
call
(13) at (14) .
Sincerely yours,
District Manager
Enclosure (15)
Exhibit 1b
Fill-ins for Request for MER (Exhibit 1a)
1. Date.
2. Name and address of treating source.
3. Salutation.
4. Claimant's name.
5. Claimant's Social Security number.
6. Claimant's date of birth.
7. Claimant's sex.
8. Patient or clinic number assigned by the treating source, if any.
9. Impairment(s) alleged by claimant.
10. Earliest date for which medical evidence is requested as determined below:
Show the later of:
a. 12 months prior to the application date or
b. Alleged date that impairment first bothered the claimant (item 1 of the SSA-3368
or item 38 of the SSA-3820).
11. Latest date for which medical evidence is requested as determined below:
Show the earlier date of:
a. Date insured status or prescribed period expired or
b. The current date.
12. If the SSA-3368/3820 indicates any tests were performed by this treating source,
enter them here. If no tests are alleged, show "no tests specified at this time."
13. CR's name.
14. Telephone number for CR.
15. Enclose a self-addressed mailing label to return records to the FO. If the treating
source is in the U.S., use a business reply envelope; if in Mexico, use a non-franked
reply envelope.
Exhibit 2a
Letter to Medical Source Requesting Medical Evidence of Record (MER)
(Spanish Version)
(1) . Paciente: (3)
Dirección: (4)
SSN: (5)
Fecha de Nacimiento: (6)
Sexo: (7)
(2)
_____________________________
_____________________________
_____________________________
Estimado Doctor:
Su paciente ha solicitado beneficios del Seguro Social de los Estados Unidos por incapacidad
para trabajar. Esta agencia está encargada de obtener información médica para determinar
si tiene derecho a recibir beneficios. El paciente indica que está incapacitado por
padecer (8) .
Favor de preparar un resumen clínico y/o enviar copias de sus expedientes médicos
correspodientes al período de (9) a (10) .
Solicitamos únicamente información ya existente. No queremos que se efectúen estudios
especiales para el informe ya que el paciente tendrá que pagarlos.
Favor de incluir los datos:
___________ (11) __________________
_____________________________
Si se cobra para el servicio de copiar, tenga la bondad de incluir la cuenta detallada
con las pruebas de archivo. La Administración del Seguro Social de EE.UU. pagará hasta
15 dólares por copias de archivos medicales o de reportes narrativos del médico.
Le agradecería su pronto atención a esta petición. Si tiene cualquier preguntas, llame
por
(12) a (13) , por favor.
Atentamente,
Gerente de Distrito/Ramo
Adjunto (14)
Exhibit 2b
Fill-ins for Request for MER (Exhibit 2a)
1. Date.
2. Name and address of treating source.
3. Claimant's name.
4. Claimant's address.
5. Claimant's Social Security number.
6. Claimant's date of birth.
7. Claimant's sex.
8. Impairment(s) alleged by claimant.
9. Earliest date for which medical evidence is requested as determined below:
Show the later of:
a. 12 months prior to the application date or
b. Alleged date that impairment first bothered the claimant (item 1 of the SSA-3368
or item 38 of the SSA-3820).
10. Latest date for which medical evidence is requested as determined below:
Show the earlier date of:
a. Date insured status or prescribed period expired or
b. The current date.
11. If the SSA-3368/3820 indicates any tests were performed by this medical source,
enter them here. If no tests are alleged, show "No necesitamos ningun otro examen
ahora" (We do not need any other exam now).
12. CR's name.
13. CR's telephone number.
14. Enclose a self-addressed mailing label to return records to the FO. If the medical
source is in the U.S., use a business reply envelope; if in Mexico, use a non-franked
reply envelope.
Exhibit 3a
Authorization for Consultative Exam (CE)
To: (1) .
______________________
______________________
|
SSN: _____ (4) _____________
Name: _ __ (5) __________
If you have any questions, please call our office at: (6) .
|
From: Social Security Administration __________ (2) ________________ ______________________________ ______________________________
|
* Receiving report:* _________(7)_______ * (SSA Manager)
|
Claims Representative Signature (3) .
|
* Accounting Classification:
* CAN = 4005113 SOC = 2533
|
Doctor: Please perform the listed services below which are hereby authorized. Complete
the bottom half of this form, sign it, and attach the form to your report(s) and mail
them to the SSA office shown above. This exam will be paid for by the Federal government
based on a set fee schedule. ________________________________________________________________
Service Description & Approved Fee Amounts
(8)
===================================================
Date of Service Description of Service Amount
______________________________________________________________
Pay this Amount $ (10) .
Certification
I, (11) , do hereby certify that I am a (12) . and that I am duly authorized to make this certification for and on behalf of (13) (patient). I further certify that the attached invoice is correct and that it corresponds in
every particular with the services contracted for and does not exceed my usual customary
fee. I further certify that the amount is true, correct and unpaid. As vendor, I certify
there has been no discrimination on the grounds of race, color, national origin or
handicap in the performance of this contract..
(14)
Signature
Exhibit 3b
Completion Procedures for CE Authorization Forms (Exhibit 3a)
FO completes these blocks:
1. CE provider's name and address.
2. FO's address.
3. CR's signature (print name below signature).
4. Claimant's SSN.
5. Claimant's name.
6. FO telephone number.
7. Manager's or designee's signature (show "by manager's designee").
8. Description of services requested and DDS approved amounts.
CE provider completes these blocks:
9. Date, description of services performed and fee requested.
10. Total amount of fees charged.
11. Name of person certifying the CE (e.g., Dr. Miguel Adams).
12. Title of person certifying the CE (e.g., M.D.).
13. Name of the claimant.
14. Signature of CE provider (must be original).
After receipt of the CE authorization and the vendor's invoice, prepare a third party
draft to cover all requested fees that do not exceed the approved amount(s). Be sure
to use the OIO CAN and SOC on the third party draft.
Exhibit 4
Letter to Claimant Requesting Attendance at CE
(English Version)
(Claimant's Name and Address)
Your application for Social Security disability benefits has been received by this
agency for consideration. Additional current medical information is needed and a special
examination can best provide this information. In order to save time, we have authorized
an examination(s) for you by:
( ) You should call the above office(s) for an appointment as soon as possible.
( ) We have made an appointment for you on ________________________ at _____________________________
a.m./p.m.
( ) Type of examination or test: _____________________________.
The examination(s) will be performed at Federal government expense and at no cost
to you.
If you fail to make/keep the appointment at the established time, and if you do not
notify us of the reason you are unable to appear for the examination(s) by 24 hours
before the examination time, we may make a determination based on the medical information
we currently have on file (if any). The lack of complete information about your medical
condition could cause us to determine you are not disabled or blind.
Be sure to return the enclosed Claimant Response Form before the appointment day.
If you have any questions, please call us immediately at ______________.
Sincerely yours,
District/Branch Manager
Enclosures (2)
Exhibit 5
Letter to Claimant Requesting Attendance at a CE
(Spanish Version)
(Name and Address of Claimant)
Su solicitud de beneficios del Seguro Social por incapacidad ha sido recíbido por
esta agencia para evaluación. Será necesario conseguir más evidencia médica y la mejor
manera de conseguirla es mediante un examen especial. Para ahorrar tiempo, hemos autorizado
que sea examinado por:
( ) Deberá llamar a la oficina de este doctor(es) inmediatemente para hacer una cita.
( ) Le hemos hecho una cita para el día ______________________________.
El examen(es) será pagado por el Gobierno Federal y usted no tendrá que pagar nada.
Si no hace su cita o si no acude en la fecha indicada y no nos avisa la razón por
la cual no podrá acudir 24 horas antes de la hora de su examen, haremos nuestra decisión
basándonos solamente en la información contenida actualmente en su expediente. Es
probable que ésto no demuestre que está usted incapacitado o ciego.
POR FAVOR asegúrese de regresar la carta adjunta antes de la fecha ahí indicada para
acusar recibo de esta carta. Si tiene preguntas sobre el examen, por favor comuníquese
de inmediato con nosotros por telefono al numero _____________________________.
Muy atentamente,
Director
Adjunto: 2 formas
Exhibit 6
Letter to Representative Payee Applicant Requesting Claimant Attend a CE
(English Version)
(Rep payee's name and address)
This letter is about the application for Social Security disability benefits you have
filed on behalf of _____________________________. Additional current medical information
is needed and a special examination can best provide this information. In order to
save time, we have authorized an examination(s) for the person for whom you have filed
an application by the following doctor(s):
( )You should call the above office(s) for an appointment as soon as possible.
( )We have made an appointment for the claimant on ______________________ at ______________________
a.m./p.m.
( ) Type of examination or test: ____________________________________.
The examination(s) will be performed at Federal government expense and at no cost
to you or the claimant.
If the appointment is not kept at the established time, and if you do not notify us
of the reason the claimant is unable to appear for the examination(s) by 24 hours
before the examination time, we may make a determination based on the medical information
we currently have on file (if any) for the claimant. The lack of complete medical
information could cause us to determine that _____________________________ is not
disabled or blind.
Be sure to return the enclosed Claimant Response Form before the appointment day.
If you have any questions, please call us immediately at _____________.
Sincerely yours,
District/Branch Manager
Enclosures (2)
Exhibit 7
Letter to Representative Payee Applicant Requesting Claimant to Attend CE
(Spanish Version)
(Rep Payee's Name and Address)
Esta carta se refiere a la solicitud de beneficios del Seguro Social por incapacidad
que usted hizo a nombre de ________________________________. Será necesario conseguir
más evidencia médica y la mejor manera de conseguirla es mediante un examen especial.
Para ahorrar tiempo, hemos autorizado que sea examinado por:
( ) Deberá llamar a la oficina de este doctor(es) inmediatemente para hacer una cita.
( ) Le hemos hecho una cita para el día ________________________________.
El examen(es) será pagado por el Gobierno Federal y usted no tendrá que pagar nada.
Si no hace su cita o si no acude en la fecha indicada y no nos avisa la razón por
la cual no podrá acudir 24 horas antes de la hora de su examen, haremos nuestra decisión
basándonos solamente en la información contenida actualmente en su expediente. Es
probable que ésto no demuestre que está incapacitado o ciego.
POR FAVOR asegúrese de regresar la carta adjunta antes de la fecha ahí indicada para
acusar recibo de esta carta. Si tiene preguntas sobre el examen, por favor comuníquese
de inmediato con nosotros por telefono al numero _____________________________.
Muy atentamente,
Director
Adjunto: 2 formas
Exhibit 8
Claimant Response Form
(English Version)
Claimant: _____________________
SSN: _____________________
Please check the proper box below to let us know whether you will keep the examination
or test scheduled for you on (day, date) at (time) .
______ I will keep the appointment.
______ I cannot keep the appointment because ___________________ __________________________________________________________
__________________________________________________________
IMPORTANT: Sign, date and mail this form immediately, using the pre- addressed envelope provided
or telephone ____________ at ______________.
(Claims Representative) (Telephone #)
______________________ _____________________
Your signature Date
Exhibit 9
Claimant Response Form
(Spanish Version)
Reclamante: _______________________
Numero De Reclamación: _______________________
Favor de marcár la caja debajo para informarnos de haber recíbido la noticia de examanación
médica para el día ___________, fecha ____________________a las _____________________________.
____ Atenderé la cita
____ No atenderé la cita porque ___________________________________ _______________________________________________________________
IMPORTANTE: Firme, ponga la fecha, y envié por correo inmediatemente, usando el sobre
con la direción proporcionada, o llame por telefono al numero _______________________.
_____________________________ ____________________________
Su firma Fecha
Exhibit 10
Foreign Claims
Report of Expenditures via Third Party Draft
ATTN: Management and Program Analyst
FAX: 410-966-3196
Reporting Period:______________________
FO:_________________________________
Charged to:
SOC: 2533
CAN: 4005113
Draft Date Claimant’s Name SSN Paid To Amount
_______________________________________________________
_______________________________________________________
_______________________________________________________
Fax the above report to OIO by the 15th of the month following the end of each calendar quarter. For example, the report
of October – December quarter should be faxed by January 15th.
Exhibit 11
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