BASIC (03-86)

DI 43535.015 Medical Requests from Foreign Agencies

Requests for medical evidence from foreign agencies may be received in a variety of formats. In some instances medical information from a foreign agency may be provided on a standardized form while the evidence in other requests may take the form of a handwritten statement by a physician. Style will vary from country to country. Generally, the examiner will receive a totalization folder from the totalization module containing a letter or form from the foreign agency requesting the medical information. In addition, the file may contain one or more pieces of medical evidence, (a standardized form, physician's report, or medical evidence submitted by the claimant), and occasionally a consent statement (SSA-827) obtained by the module authorizer. The file may also include a statement of consent obtained by a foreign agency allowing us to submit any evidence in our possession to the foreign agency. The foreign consent statement, however, will not concern the examiner. The foreign consent statement is the responsibility of the totalization module.

Certain countries may have a specific form for requesting medical evidence or summarizing the medical condition that may include statistical data about the claimant, a brief medical history, allegations regarding the claimant's impairment(s), or a list of the types of examinations or tests required. The following is a summary by country of the forms that will be frequently encountered in the totalization medical requests.

A. The Italian folder

Italy generally requests medical evidence in a letter under the heading “Institute Nationale della Providenza Sociale”, “Certificato Medico” . The folder may also include a physician's report, questionnaires, and certifications of birth and marriage. To date, Italy has requested only general physical examinations, making it necessary for the examiner to determine from the information on the “Certificato Medico”, what examinations are needed. However, Italy has agreed to start using a standard form titled Request for Medical Examination or Medical Evidence. This form should provide more specific information about the evidence or examination needed. Although Italy has agreed to use the form, we are not certain when the form will be printed.

“Certificato Medico” (Mod. SS3). This form will provide the name and address of the individual, various work activities and a summary of the medical history, physical condition, system review, and diagnosis. (See Exhibit 2.)

“Relazione Medico Legale (SS4TP)”, “Referta Medico Legal (SS4)”, “Perizia Medica Dettagliata (Comunita Europee--E213)”. These forms are Italian medical questionnaires. Italy may occasionally submit one of these forms and it will appear untranslated in the folder. The forms may also be accompanied by a letter asking SSA to complete the form attached. The examiner should disregard any of the above forms. In our negotiations, the Italian agency has indicated they will accept our consultative reports in the style prepared.

B. The German folder

Germany provides identifying information and indicates the type of medical evidence needed on the “D/USA 3”. Where a general physical examination is requested, Germany will usually complete item 3 of the “D/USA 3”. If special tests or examinations are needed, Germany will check the block marked “D/USA 6A” in item 2 of the “D/USA 3” and include the form with the “D /USA 3” when forwarding the request.

“D/USA 3” German transmittal request form. (See Exhibit 3.)

“D/USA 6A” Disability Liaison Form. A form used by Germany to request specific consultative examinations and tests. (See Exhibit 4.)

“D/USA 7” Consent Statement. A declaration of consent authorizing SSA to obtain medical reports from physicians and hospitals for Germany, and/or authorization for SSA to release to Germany medical information in SSA files. (See Exhibit 5.)

Although these instructions are temporary, the format will essentially serve as a model for the development of all foreign medical requests and the manner in which medical information will be exchanged with foreign countries. However, as we gain experience, and as requests are received from other countries, some changes in the instructions may be necessary to accommodate the specific requirements of certain foreign countries.

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