DI 43520.001 SSA-423-U3 Request for Services (Foreign Disability Case)
A. Use of SSA-423-U6
Use form for correspondence with the FSP regarding additional development in foreign disability cases as follows (initial and supplemental requests only):
Development of medical evidence.
Development of nonmedical evidence.
Request for verification of qualifications of foreign medical source.
Assistance to the claimant.
B. Preparation of the SSA-423-U6
Prepare an original and 5 copies as follows: Original, Courtesy, and FSP Budget and Fiscal Officer Copy to the Department of State, and one copy for the Office of Data Development, OMBP. Place the folder copy and the District Office Copy in the folder. Route a copy to the ALJ or Appeals Council in appropriate cases. If a border district office is involved, send the DO copy of the SSA-423-U6 to the DO. (See Exhibit E in DI 43520.070E for routing by means of an Optional Form 41).
Insert division and section file symbols, current date, current SSA appropriation number, current allotment and organization code, account number, number holder's name if disabled child or disabled widow filing, and name and address of the disabled individual. Use interim action code 21 on requests to the State Department.
SSA Appropriation Number
Enter the number applicable to the fiscal year during which the initial request originates. The SSA appropriation number for the fiscal year, October 1, 1985, through September 30, 1986, is 7568704. Each succeeding year the third digit of the appropriation number should be changed to correspond to the final digit of the then current fiscal year, (e.g., for fiscal year 1987, the appropriation number will be 7578704.
Allotment and Organizational Codes
Enter the Allotment Code 5113, followed by the object class code for Contracts for Foreign Claims Services 253P (5113-253P). These numbers do not change with the fiscal year.
Complete the five numbered items as appropriate. Items (1) or (2) should be checked in every case; occasionally both may be checked. When a consultative examination is being requested, check the box that reflects the type of examination needed (the FSP will select a qualified doctor to perform the indicated examination). Specify in Item (4) the tests needed. Do not generalize (e.g., “x-rays”) or use “open-end” authorizations. Use Item (5) to call attention to special information. It will not be necessary to repeat data already included on the report form (e.g., the physician should submit a complete narrative summary of his findings). Place the claimant's date of birth in the lower right hand corner.
Remarks-- Enter in the Remarks block any additional information such as the name and address of the medical source whose qualifications are to be verified. Describe evidence to be obtained in the clearest and most complete language possible. Do not use SSA or medical abbreviations such as NH, BUN, PFS, etc. (See DI 43510.005-DI 43510.020 for development instructions.)
Enclosures-- If thought to be appropriate by the disability examiner, a photocopy of the original of any medical evidence or material evidence or material which may be of assistance to the FSP or the examining physician should be enclosed with the transmittal.
A copy of a summary of the evidence of record, or comments by the medical consultant staff may also be attached for the use of the examining physician.
Routing -- The SSA-423-U6, with enclosures, should be routed to the section secretary or other designated person, who will enter the control number. A record of control numbers should be kept by the secretary or other designated person.
C. Folder disposition
Return the folder to the MOD pending receipt of the requested development (See DI 43510.070 for diary control instructions).