TN 1 (01-01)
DI 13015.070 Title II or Title XVI – FO Interview – Medical Folder Not Located - “Currently Disabled” Step
Even though we are unable to find the folder with the critical medical evidence related to the CPD, under the regulations SSA can still determine if the individual is “currently disabled”. The DDS “currently disabled” determination (DI 28035.010) legally establishes that an individual’s benefits should continue, at the earliest point in time, without the costly reconstruction of the prior medical evidence. This “currently disabled” determination becomes the CPD for future medical reviews.
1. Conducts Interview
Conduct the medical interview (see DI 13005.030 for an overview of the CDR interview process). Also see DI 11070.030 – Age 18 medical redetermination cases. Specifically, follow these guidelines:
Advise the individual that, although the appropriate folder/medical evidence cannot be located, this action will not adversely affect his/her claim.
Obtain the names, addresses and telephone numbers of all medical sources who have treated the individual during the last 12 months prior to the interview date. The object is to secure a history of at least one-year of medical treatment.
NOTE: DO NOT DEVELOP medical sources for the 12-month period preceding the CPD (even if you are able to determine this date without DDS assistance) unless specifically requested to do so by the DDS. See DI 13015.090.
Form SSA-454-BK (Report of Continuing Disability Interview); (See DI 13005.040 regarding Child Cases);
Form SSA-827(s) (Authorization for Source to Release Information to the Social Security Administration) for every medical source listed; and
Any State specific Medical Releases.
Title XVI Child: Obtain either the Form SSA-3375-BK, SSA-3376-BK, SSA-3377-BK, SSA-3378-BK and SSA-3379-BK (Function Report - Child) [Separate form for each age group: Birth-1, 1-3, 3-6, 6-12, 12-18.] -One of these forms must be completed whenever an SSA-3820-BK is required. (See DI 11005.016A.2.e. and
DI 11005.030 - DI 11005.035).
Inquire about activities of daily living, complete the observations, and provide any other information relevant to the current disposition. Obtain information without being redundant or recording unnecessary information, e.g., onset and working history already contained/reflected in the file.
Advise the individual that he/she may be contacted again for additional information concerning other medical sources. Assure the individual that he/she will not be adversely affected just because the medical folder is lost.
2. Interview Completed - Routing Folder
Route the folder to the DDS via a Form SSA-408 (Route Slip) or designated regional routing form/flag.
Annotate the SSA-408 “CDR Lost Folder/Medical Evidence”. Follow
DI 28035.000 ff. Advise FO if full reconstruction is necessary”.
DI 40525.000 ff.: PC instructions for the processing CDR lost/replacement folders and medical evidence.
DI 28035.000 ff.: DDS instructions for processing CDR lost/replacement folders and medical evidence.