When requesting MER from a medical source, the FO may use the guide language in the
model letter. The letter provides the essential information that we should furnish
when requesting a medical source to send us its records. The language may be adapted
to fit the situation and direct the source to provide the specific information we
Social Security Adminisrtration
(Field Office Address)
(Name and address of medical source)
Re: (Enter claimant's name, SSN and address)
We are writing to obtain medical evidence on behalf of _____________ who has applied
for benefits based on disability/blindness under the Social Security Act. The claimant
has asked us to request the evidence because we are responsible for determining whether
the claimant is disabled or blind.
To make such a determination, we need medical evidence that will enable us to make
an independent determination as to the nature, severity, and duration of the claimant's
impairment(s). Thus, we are seeking evidence of sufficient detail that will include
medical history, clinical and laboratory findings, clinical course, therapy and response
to treatment, diagnosis, and prognosis. We request that you furnish us either a report
of such evidence, or if such evidence is unavailable, a statement to that effect.
The original authorization signed by the claimant is enclosed. We are also enclosing
a report form for your convenience, although a narrative report on your stationery
or copies of your records are perfectly acceptable. If available, please also include
copies or summaries of pertinent hospital or consultative reports.1
 [FOR ADULTS] We would also like to have a statement, based on your medical findings,
expressing your opinion about the claimant's ability, despite the functional limitations
imposed by the impairment(s), to do work-related (insert A, B, or both, as appropriate).
(2) [FOR CHILDREN] We would also like to have a statement, based on your medical findings,
expressing your opinion about the child's functional limitations in learning, motor
functioning, performing self-care activities, communicating, socializing, and completing
tasks (and, if the child is a newborn or young infant from birth to age 1, responsiveness
We are authorized to pay up to _________ for a report of the evidence requested and
you may include an invoice with the report.3 If you are requesting payment for the evidence, the invoice must include the following
The claimant's name and Social Security number;
Your employer identification number if you are incorporated; or
Your Social Security Number if you are unincorporated.
Payment cannot be made without this information. A preaddressed, stamped envelope
is enclosed for your reply. If you have any questions, please call this office.
Your prompt response will help ensure a speedy decision on this claim. Thank you for
Field Office Manager
Insert A - physical activities such as sitting, standing, walking, lifting, carrying,
handling objects, hearing, speaking, and traveling.
Insert B - mental activities such as understanding and memory; sustained concentration
and persistence; social interaction; and adaptation.
1Omit this sentence if the request is to a hospital.
2Omit this sentence in statutory blindness claims.
3Omit this sentence if the request is to a Federal source.