DI DAL22510.045 Arranging For A Consultative Examination
See DI 22510.045
The attached bilingual regional form may be used by the district/branch offices on
an optional basis in the following situations:
During the initial interview.
During a work activity only continuing disability review when ODO/TAS has determined
that a medical review is required by the DDS after the DO/BO completes its actions.
During the development of a CDR when the beneficiary has returned to work and there
is a medical re-examination diary date. (These cases generally require a DDS medical
In cases where the claimant contacts the DO/BO for assistance with a DDS mailed form
or where the DDS has asked the DO/BO to assist the claimant in scheduling a CE.
If the file does not contain the form and it is not documented that the claimant refused
to sign it, the DDS should assume that the claimant was not asked to sign it.
The claimant's refusal to sign the statement cannot be used to eliminate any of the
established procedural steps in the CE process as required by the instructions to
STATEMENT OF CLAIMANT OR OTHER PERSON
NAME OF WAGE EARNER, SELF-EMPLOYED PERSON OR SSI CLAIMANT
SOCIAL SECURITY NUMBER
NAME OF PERSON MAKING STATEMENT (If other than above wage earner, self-employed person,
or SSI Claimant)
RELATIONSHIP TO WAGE EARNER OR SSI CLAIMANT
UNDERSTANDING THAT THIS STATEMENT IS FOR THE USE OF THE SOCIAL SECURITY ADMINISTRATION,
I HEREBY CERTIFY THAT —p>
It has been explained to me that my application(s) for disability benefits, both Social
Security and/or Supplemental Security Income, will be decided by an agency of the
State government on behalf of Social Security. I understand that I may be requested
to go for a medical examination(s) at Social Security's expense if the records from
my own doctor and/or hospital do not contain enough information to make a medical
decision on my application(s). I agree to go to this medical examination if required
for a determination. If I am unable to attend such examination, I will immediately
telephone the State Agency. I also understand that if travel is necessary, I can request
reimbursement from the State Agency.
If I fail to notify the State Agency that I cannot attend an examination, I understand
my application(s) for disability benefits will have to be determined based on the
information in my file and could result in a denial.
CHECK IF APPLICABLE ----- I cannot afford to pay out-of-town travel.
TENGO ENTENDIDO QUE ESTA DECLARACION ES PARA EL USO DE LA ADMINISTRACION DEL SEGURO
SOCIAL, Y POR MEDIO DE LA PRESENTE CERTIFICO QUE:
SE ME EXPLICO QUE MI SOLICITUD(ES) PARA BENEFICIOS DEL SEGURO SOCIAL Y/O DEL SEGURO
DE INGRESO SUPLEMENTAL POR INCAPACIDAD SERA DETERMINADA POR UNA AGENCIA DEL ESTADO
PARA EL SEGURO SOCIAL. ENTIENDO QUE ES POSIBLE QUE SE ME PIDA ACUDIR A UN EXAMEN MEDICO
O SUMETERME A UNO(S) ANALISIS DE LABORATORIO QUE SERAN PAGADOS POR EL SEGURO SOCIAL
SI ACASO LOS EXPEDIENTES DE MI MEDICO Y/O HOSPITAL NO CONTIENEN SUFICIENTES INFORMES
PARA HACER UNA DECISION MEDICA SOBRE MI SOLICITUD. ESTOY DISPUESTO A PRESENTARME A
ESTE EXAMEN SI ME LO PIDEN. SI NO PUEDO ACUDIR A ESTE EXAMEN, ME COMUNICARE POR TELEFONO
IMMEDIATAMENTE PARA DAR AVISO A LA AGENCIA ESTATAL. TAMBIEN ENTIENDO QUE SI HAY NECESIDAD
DE VIAJAR A DICHO EXAMEN, PODRE PEDIR UN REEMBOLSO DE LA AGENCIA ESTATAL PARA CUBRIR
ENTIENDO QUE MI SOLICITUD DE BENEFICIOS POR INCAPACIDAD SERA DETERMINADA SOBRE LA
INFORMACION EN MI EXPEDIENTE Y PODRIA SER DENEGADA SI NO INFORMO A LA AGENCIA QUE
NO PODRE CUMPLIR CON LA CITA.
INDIQUE CON UNA MARCA SI APLICA ----- NO PUEDO PAGAR LOS GASTOS DE VIAJE FUERA DE
FIRMA ___________________________ FECHA ________________ TELEFONO # ___________
SIGN HERE ______________________ DATE __________________ PHONE # _____________