BASIC (03-86)

DI 13501.025 Referral Procedure

A. The SSA-1407-U4 (See DI 13501.035, Exhibit 1)

The SSA-1407-U4 is a form which is used to refer individuals to the State VR agency.

When making a referral to VR, prepare an original and two copies of the SSA-1407-U4 as follows:

Item 1-State of residence of the individual
Item 2-Enter the individual's own SSN
Item 2A-If CDB or DWB, enter SSN of primary beneficiary
Item 3-Enter the individual's name
Item 4-Enter month, day and year of birth
Item 5-Check appropriate box
Item 6-Check appropriate block
Item 7-Show the number of years of formal education
Item 8-Enter the DDS code for the State of residence
Item 9-Enter the individual's full address and the DO code
Item 10-Check block A
Item 11-Show by checks all payments allowed (SSDI)
Item 12-Check one box indicating individual's primary impairment
Item 13-If the folder contains a copy of the individual's plan for self-support, check the block and attach a copy of the plan
Item 14-Enter a description of all material sent to VR agency, e.g., Medical Report from Dr. Smith dated 7/6/76
Item 15-Enter any special information the VR agency might find useful, e.g., an urgent need for a particular VR service
Item 16-Signature of the examiner who makes the referral
Item 17-Date of referral

1. Attachments to the SSA-1407-U4

  1. Form SSA-1994, Cover Sheet (Confidential Information)

  2. A copy of the determination (SSA-831-U5 SSA-832-U5 or SSA-833-U5 and SSA-834-U4)

  3. Form SSA-3368-BK, SSA-3369-BK, SSA-3820-BK, SSA-3441-BK (Photocopy)

  4. Current medical reports (photocopy)

  5. Vocational evaluation reports (photocopy)

  6. Any other material which may be useful to the VR agency (photocopy)

2. Routing of the SSA-1407-U4

Send the original and one copy with attachments to the mailroom by OF-41. Insert the remark, “Send to (name of State) VR agency.” Place the remaining copy in the folder. The Privacy Act requires accounting for all routine disclosure. The folder copy of the SSA-1407-U4 satisfies this requirement.

B. Rereferral Cases

In rereferral cases, the responsible component must complete items 1-12 and 14-17 on the SSA-1407-U4. Information entered in most of these items is taken from the original SSA-1407-U4 returned with the DO development.

Items 1-8 may be directly transcribed from the original form.
Item 9-If the responsible component is aware of a change in the individual's address and the DO code, enter the updated information. Otherwise, transcribe directly from the original form.
Item 10-Check block B. “Rereferral-No Longer Refusing VR Services.”
Items 11,
11A, and 12
-may be directly transcribed from the original form.
Item 14-Since a copy of the form will be associated with the claims folder, enter in item 14 a description of the material sent to the VR agency in order to document the disclosure of the information to the VR agency.
Item 15-Enter any special information the VR agency might find useful, e.g., the DO has indicated that there is an urgent need for a particular rehabilitation service.
Item 16-The SSA-1407-U4 should be signed by the examiner who makes the rereferral.
Item 17-Enter the date of referral

To Link to this section - Use this URL:
DI 13501.025 - Referral Procedure - 12/28/2004
Batch run: 01/27/2009