TN 2 (05-10)

DI 27025.025 Personalized Explanation Preparation Guide Form

NOTE: Enter the corresponding fill-in(s) as appropriate. Delete “s” or multiple words that should not be part of the sentence.

__

(Initial)

The following report(s) was/were used to decide your claim.

__

(Recon - additional medical evidence)

The following reports was/were used to decide your claim in addition to those listed on our previous notice.

__

(Recon - no additional medical evidence)

Since no additional evidence was submitted, the reports listed in our previous notice was/were used to decide your claim.

__

(Initial-no medical evidence).

We were unable to obtain any evidence needed to evaluate your claim

__

(Show name of medical source and date of report).

__

(Sufficient medical evidence - not all reports obtained)

Additional reports were not obtainable; however, the ones shown above had enough information to evaluate your condition.

__

(Optional - partially favorable allowances) The determination on your claim was made by a State agency. It was not made by your own doctor or by other people or agencies writing reports about you. However, any evidence they gave us was used in making this determination. Doctors and other people in the State agency who are trained in disability evaluation reviewed the evidence and made the determination based on Social Security law and regulations.

__

(Optional - Reconsideration claims)

In denial determinations enter the decision paragraph(s) as indicated in the charts in DI 26530.025 through DI 26530.050.

__

(Enter impairment(s) evaluated. Exercise care not to offend or upset the claimant.)

You said that you are unable to work because of:

__

We have evaluated blindness-related impairments only because you do not meet the earnings requirements for non-blind disability benefits.

__

(Enter what the medical evidence shows)

The medical evidence shows:

__

Based on your description of the job you performed as a (1) for the past (2) years, we have concluded that you have the ability to do this job. (Fill-ins: (1) job title, (2) no. of years).

__

We realize that your condition keeps you from doing (1), but it does not keep you from doing (2). Based on your age (3), education (4), and past work experience you can do other work.

Fill-ins: (l) Use “any of your past jobs” or for those claimants who haven't worked, use “some types of work,” (2) specify the claimant's capacity to do other work which is less demanding (refers to exertion, mental, skill level) or requires less physical effort in general terms, e.g., lighter work, (3) age, (4) education.

__

(Optional for Reconsideration claims)

Add a concluding statement, if applicable, for the specific denial as indicated in the charts in DI 26530.025 through DI 26530.050.


To Link to this section - Use this URL: