The SSA-827 authorizes the claimant’s medical source to release information to SSA. FO 872 will:

1. a. 

   obtain two signed SSA-827 forms from the claimant (For more information on completing the SSA-827, see DI 11005.055.);

2. b. 

   use one SSA-827 to request that the medical provider complete the EHH Checklist;

3. c. 

   obtain a bar code fax coversheet via the Electronic Disability Collect System (EDCS) and fax the second SSA-827 into the Electronic Folder (EF) if the claimant is filing for both disability insurance benefits (DIB) and EHH Medicare; and

4. d. 

   retain the second SSA-827 to fax into NDRed after establishing the MBR. After confirming that the SSA-827 is in NDRed, shred the original.

The purpose of the EHH Checklist is to obtain information from the claimant’s medical source regarding the claimant’s diagnosis and presence in Lincoln County, Montana. The claims representative (CR) will use the completed EHH Checklist to determine if the claimant’s condition meets the medical requirement. The EHH Checklist may also provide evidence of presence in Lincoln County, Montana. (For policy on using the EHH Checklist as proof of presence in Lincoln County, Montana, see HI 00803.040B. and HI 00803.040C.). See images of the EHH Checklist and cover notice in HI 00803.050B.3. in this section. 

1. a. 

   FO 872 takes the following actions to obtain a completed EHH Checklist:

   • •

     complete step 1 (identify the individual) on the EHH Checklist;

   • •

     fill in the FO’s fax number on the cover notice; and

   • •

     forward the EHH Checklist with the cover notice to the claimant’s medical source with a signed SSA-827.

     NOTE: The name of source will appear in “Remarks” in the MCS claims path or the paper application.

2. b. 

   The claimant’s medical source will take the following actions to complete and return the EHH Checklist:

   • •

     complete step 2 (identify the asbestos-related condition(s) and its date of diagnosis) and step 3 (identify presence in Lincoln County, Montana);

   • •

     fill in printed name, physician’s signature, and date; and

   • •

     return it by fax to the number provided on the cover notice or mail it to the Kalispell FO located at 275 Corporate Drive, Ashley Square Mall, Suite D, Kalispell, MT 59901.

     NOTE: The medical source does not need to provide the supporting medical evidence.

3. c. 

   FO 872 will take the following actions to store the completed EHH Checklist:

   • •

     obtain a bar code fax coversheet via the Electronic Disability Collect System (EDCS) and fax the completed EHH Checklist into the Electronic Folder (EF) if the claimant is also applying for disability benefits or has a pending disability claim;

   • •

     retain the completed EHH Checklist until the MBR is established. Once the MBR is established, fax the EHH Checklist into the EF using NDRed. Use a Document Type of ‘Other’. The document description should show ‘EHH Checklist’; and

   • •

     confirm that the EHH Checklist is in the EF and legible, then shred the original.