TN 11 (09-11)
DI 81010.125 Receiving Medical Evidence in the Field Office
A. Receiving paper medical evidence prior to case transfer
In all cases, when a claimant submits evidence to the field office (FO), document the certified electronic folder (CEF) to show it was received.
In the “Remarks” section of the Electronic Disability Collect System (EDCS) 3367:
Annotate that the claimant, applicant, or representative submitted evidence to the FO ( e.g., hospital summary, physician notes, medical report) ; and
Show the name of the source for each document (e.g., Dr. John Smith, Mercy Hospital).
NOTE: We do not consider other disability-related forms, such as function reports, medical evidence.
1. Terminal Illness (TERI), Presumptive Disability (PD), Quick Disability Determination (QDD), Compassionate Allowance (CAL) or special arrangement cases
a. Evidence is 15 pages or less
When the evidence submitted totals 15 pages or less:
Create a barcode for each source of evidence, using the applicable document type
“0180 - Claimant-Supplied Evidence” or, “5032 - Attorney-Supplied Evidence”;
Fax the evidence into the CEF per Faxing Documents into the Certified Electronic Folder (CEF) Using Barcodes DI 81010.090;
Verify in eView under the “Case Documents” tab that you successfully faxed the evidence into the CEF and that all pages are legible; and
Shred the evidence after you verify that you successfully faxed it into the CEF, unless other procedures require you to return the evidence to the claimant.
NOTE: Store the evidence in the official paper folder if the official folder is paper and the evidence was faxed into an electronic folder.
b. Evidence is more than 15 pages
When the evidence submitted totals more than 15 pages handle the evidence per instructions DI 81010.125A.2. in this section.
If regional or local arrangements are in place for faxing medical evidence into the CEF, or if time permits, you may fax more than 15 pages of medical evidence into the CEF for these cases.
EXCEPTION: Do not attempt to fax x-rays or actual medical test tracings (e.g., EEGs, EKGs, pulmonary function studies). Handle those per instructions DI 81010.125A.2. in this section
2. All other cases (not TERI, PD, QDD, CAL, or special arrangement cases)
For all other cases:
Annotate the EDCS Routing Form “Attached medical evidence to be scanned”. Do not make any annotations on the actual medical evidence; and
Forward the medical evidence under cover of the EDCS Routing Form along with the signed SSA-827 (Authorization to Disclose Information to the Social Security Administration) forms unless other regional agreements apply.
NOTE: Do not maintain paper copies of the medical evidence in the FO. Do not create a barcode coversheet.
B. Receiving paper medical evidence in the FO after transfer to DDS or ODAR
1. If a barcode coversheet is attached to the medical evidence:
Assume that the DDS or ODAR requested the medical evidence and the sender misrouted it to the FO;
Add a message to the CEF indicating “Medical evidence received in FO from <source name> on MM/DD/YYYY.”; and
Mail the evidence to the DDS or ODAR.
NOTE: If faxing the requested material directly to the DDS, use the barcode provided by the DDS along with the fax number listed on the barcode. Do not use the FO fax number or an FO generated barcode for this material.
2. If a claimant, applicant, or third party submits medical evidence to the FO without a DDS or ODAR barcode coversheet:
Query the case in eView to see if the case is a TERI, PD, QDD, CAL, or special arrangement case; if yes, follow the instructions in DI 81010.125A.1. in this section.
Add a message or SSA-5002 (Report of Contact) to the CEF notifying the DDS or ODAR that you received claimant-supplied medical evidence and include the following:
Mail the evidence to DDS or ODAR.
C. Receiving paper medical evidence after DDS releases jurisdiction to the FO
Determine if the medical evidence duplicates evidence in the CEF by:
1. Duplicate evidence
If the evidence is an exact duplicate of evidence in the CEF before the DDS made the disability determination:
Destroy the paper document; and
Add a message to the folder, including the name of the source, that duplicative medical evidence was submitted.
2. New evidence
If all or part of the evidence is not duplicative (i.e., new evidence):
REMINDER: Receipt of new evidence may be considered an implied request for an appeal, see GN 03102.100C.2. For more information on revisions and reopenings, see Reopenings and Revisions DI 27501.005.
D. Receiving medical evidence in an electronic format in the FO
If the FO receives medical evidence in an electronic format (e.g., Compact Disc), do not print the information. Route the item received to DDS or ODAR along with any other claimant or representative-supplied evidence. Attach a label that contains the following:
Last four digits of the claimant’s SSN preceded by five “Xs” in the SSN format (e.g., XXX-XX-1234). This SSN format is necessary to ensure the privacy of the claimant if we return the electronic medical evidence to the source;
Date the FO received the electronic medical evidence; and
Name of the source that submitted the electronic medical evidence.