AGENCY
LETTERHEAD
Date:
[Fill-in]
Case
ID: [Fill-in]
Addressee
Name
Address
Line 1
Address
Line 2
City,
State, ZIP
Code
APPOINTMENT
NOTICE
We are working on your claim for disability benefits. We made one or more appointments
for you because we need more information about your condition. We will pay for the
appointment(s) and may also reimburse some travel expenses to the exam or test site
if you qualify for travel payment.
Appointment Information
|
Provider Information
|
Date and Time
|
Type of Appointment*
|
|
CE provider name
CE provider address
CE provider phone number (if
required by state)
|
Weekday
Appointment date
Appointment time with time zone
|
CE procedure specialty type(s)
|
*The provider may decide not to do some of the tests we ordered or that other tests
are needed.
Please do not call the provider to confirm or reschedule your appointment(s).
Please arrive at your appointment 15 minutes early. If you are late, the provider may choose not to see you.
Please do not bring children to the appointment unless the appointment is for the
child.
What You Should
Bring
To
The
Appointment
Bring this letter and photo 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(s). Please complete the enclosed response
form and mail it in the pre-addressed envelope provided. You should respond to our
office by [CE confirm date]. You may also fax your response form to [DDS fax number].
Please call our office immediately if you cannot attend your appointment(s) as scheduled
for any reason. If you cannot attend your scheduled appointment(s), and you would
like us to reschedule, you must give us a good reason.
If you have moved from the above address, please contact us before the date of the
appointment(s). We may need to reschedule the appointment(s) closer to where you live.
If You
Need An Interpreter
We provide a free interpreter to conduct your Social Security business. However, if
you prefer to have your own interpreter, you may do so, but with the understanding
that our own interpreter may be present. It is important that you let us know prior
to the appointment(s) if you require an interpreter or if you are bringing your own.
If
You
Want A
Copy
Of
The Report(s)
Sent
To
Your
Healthcare
Provider
If you want a copy of the report(s) from the evaluation(s) sent to your healthcare
provider, please complete the enclosed authorization form and mail it in the pre-addressed
envelope provided. You may also fax your form to [DDS fax number].
If
You
Miss A
Scheduled
Appointment
If you fail to keep an appointment without notifying us, we may make a decision based
on the evidence we already have in file. We may find that you are not eligible, or
no longer eligible, for disability benefits.
If You Have Any Questions
If you have any questions about this letter, need to contact us about the appointment(s),
or have feedback to share after the appointment(s), please call us at the number shown
between [DDS office hours]. 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:
Appointment Confirmation
Authorization to Release Consultative Examination Report (if enclosed)
Travel Reimbursement Form (if enclosed)
Privacy Act and Paperwork Reduction Act Statements
Multi-Language Insert (if enclosed)
SSA Publication No. 05-10087 (A Special Examination Is Needed for Your Disability
Claim)
Return Envelope