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.
[Claimant Full Name] identified you as someone we could contact for assistance.
It is very important that we speak to you by [10 calendar days] to confirm [Claimant Full Name]'s upcoming appointment(s).
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.
Travel to and from the appointment is [Claimant Full Name]'s 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 the appointment(s) and
we may decide [Claimant Full Name]'s case based on the evidence already in file. This
means that we could find [Claimant Full Name] is not disabled based on our rules or
that disability has ended if they are already receiving benefits.
Please call the phone number(s) 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)