When processing:
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paper claims, you can access the SSA-416-UF via the InForm website; and
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electronic claims, you can access the SSA-416-UF eform via the form selector application.
NOTE: The disability examiner (DE) may complete or assist in completing the SSA-416-UF
but only the MC, PC, or MA may sign the form. The DE cannot edit a medical evaluation
form that the MC, PC, or MA has signed.
The following chart provides instructions on how to complete the SSA-416-UF:
Form section
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Action
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1. Heading
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Fill in the claimant’s name and SSN.
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2. Period Covered
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Indicate the assessment period covered in the evaluation:
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Current evaluation - Onset date through present and the duration requirement has been met, or when the
onset is within 12 months of adjudication and the impairment does not preclude substantial
gainful activity (SGA) at the time of the assessment.
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Date last insured (DLI) - For Title II cases only, when DLI has expired in the past. Enter the DLI “(Date)”
in the space provided.
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12 months after onset - When duration is an issue, enter the “(Date)” to which you are projecting in the
space provided.
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Other period(s) - For any situation not covered by the other three blocks (multiple assessments or
closed periods).
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3. Subject
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Identify which type of medical finding you are documenting. There may be more than
one subject for each SSA-416-UF.
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4. Assessment
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Document the medical evaluation in this section. As appropriate, address the following:
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Drug Addiction and Alcoholism (DAA) materiality analysis (See Evaluating Cases Involving
Drug Addiction and Alcoholism (DAA) SSR 13-2p in DI 90070.041),
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5. Signoff block “THESE FINDINGS COMPLETE THE MEDICAL PORTION OF THE DISABILITY DETERMINATION”
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MC/PC: If an MC or PC is completing this form, check this box when the evaluation
is complete.
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MA: Do not check this box. The Social Security Act (42 U.S.C. 421(h)) authorizes only
an MC or PC to complete the medical portion of the case review and any applicable
residual functional capacity (RFC) assessment.
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Do not check this block. This block is for MC/PC completion only.
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6. Signer’s Role
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Check the appropriate box corresponding with your role in the disability determination.
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7. Signature instructions
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In all claims, sign your name, enter your office number, print or type your name,
identify the page numbers, and date the form.
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MC/PC/MA Specialty Code: Only an MC, PC, or MA will complete this field. Enter the
appropriate specialty code found in DI 24501.004.
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8. MC/PC/MA Specialty Code
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Only an MC, PC, or MA will complete this field. Enter the appropriate specialty code
found in DI 24501.004.
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IMPORTANT: Alternatively, an MA may print the form and sign in ink; identify the signer as “Medical
Advisor,” and scan the document into the EF. For guidance on completing the SSA-416-UF
in eCAT, see the most recent eCAT User Guide.