TN 17 (12-11)

NL 00705.745 Model Consultative Examination (CE) Appointment Notice and Forms

A. Model 1 CE appointment notice

   

                                                                AGENCY

                                                            LETTERHEAD

                                                                                                                 Date: _______________

                                                                                                                  Case ID: [Fill-in]    

Addressee Name 

Address Line 1

Address Line 2

City, State, ZIP Code

MEDICAL APPOINTMENT NOTICE

Dear [First Name] [Last name],

We are the office that makes decisions for Social Security. We made a medical appointment for you because we need more information about your medical condition for your Social Security disability claim. We will pay for this appointment.

Your Medical Appointment Information

Name and Address

Phone Number

Date and Time

Type of Appointment*

*The medical evaluator may decide not to do some of the tests we ordered or that other tests are needed.

Please arrive at your appointment 15 minutes early. If you are late, the medical evaluator may choose not to see you.

What you should bring to the appointment

Bring this letter and personal identification (e.g., U.S. State-issued driver’s license or non-driver identity card, U.S. passport, U.S. military ID, student or school ID). Bring any medications that you take in their original containers. Also, bring your hearing aids, eyeglasses, contact lenses, canes, or other medical aids if you use them.

What you should do next

  • Confirm that you will attend your appointment. Please complete the enclosed response form and mail it in the pre-addressed envelope provided. (Use the second sentence, only if you enclose a response form.) You should respond to our office within ten days of the date on this letter.

  • Let us know if you cannot attend your appointment, as scheduled. Please call our office immediately if you cannot attend your appointment for any reason. If you cannot attend your scheduled appointment, and you would like us to reschedule, you must give us a good reason.

If you have any questions or need assistance for the appointment

Contact us if you need help to pay for travel expenses to the appointment. We will only consider payment of these costs if you ask us promptly. Normally, we reimburse approved expenses after you attend the appointment. However, we will consider your request for advance payment if you show us that the request is reasonable and necessary.

Also, call us if you need to request special arrangements for this medical evaluation because you have a health issue that makes traveling difficult.

Let us know if you need a foreign language interpreter, a sign language interpreter, or other assistance to communicate effectively with the medical evaluator. We will arrange for interpreter services at no cost to you.

If you want a copy of the report sent to your doctor

If you want a copy of the report from this medical evaluation sent to your doctor, please provide his or her full name and address. Please complete the enclosed authorization form. (Use this statement only if you enclose an authorization form.)

If you miss the scheduled appointment

If you do not attend your appointment, we may make a decision based on the evidence we already have in your file. We may find that you are not eligible or no longer eligible for disability benefits. Please read the enclosed leaflet that explains more about the consultative examination and your responsibility for attending.

If you have any questions about this letter or need to contact us about the appointment, call Monday-Friday between 8:00 a.m. and 4:00 p.m. at the phone number below.

Thank you for your cooperation,

(NAME)__________________ 

(TITLE) __________________ 

PHONE NUMBER [Fill-in]

TTY/TRS [Fill-in]

Enclosures:

SSA Publication No. 05-10087 (A Special Examination Is Needed for Your Disability Claim)

Consultative Examination appointment confirmation form (List if enclosed.)

Authorization form (List if enclosed.)

SSA-5000 (Privacy Act Statement) (Enclose and list if you enclose the CE appointment confirmation form or authorization form.)

B. Model 2 CE appointment confirmation form

                                                                 AGENCY

                                                              LETTERHEAD

                                                                                                             Date: _______________

                                                                                                              Case ID: [Fill-in]    

Addressee Name

Address Line 1

Address Line 2

City, State, ZIP Code

Dear [First Name] [Last name],

Please check the correct box to let us know if you will attend your appointment on [Fill-in mm/dd/yyyy].

[ ] I will attend the medical appointment scheduled for my Social Security claim:

[ ] I cannot attend the medical appointment because

__________________________________________________________________.

Appointment Information

Medical Evaluator [Fill-in]

Address [Fill-in]

Date [Fill-in]

Time [Fill-in]

IMPORTANT: Please sign, date, and mail this form as soon as possible using the pre-addressed envelope provided. If you cannot attend the scheduled appointment or require additional assistance to attend, notify us immediately at (XXX) XXX-XXXX.

__________________                       ______________________

(Your Signature)                                            (Date)        

             

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to provide this information unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0555. We estimate that it will take between 5 to 30 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

C. Model 3 Authorization form for release of a copy of the CE report to the claimant’s doctor

Case ID: [Fill-in]

I, [First Name] [Last name], authorize the Social Security Administration to send a duplicate of the consultative examination report by [Fill-in name of the medical evaluator], to:

Your Doctor’s Name: __________________ 

Address Line 1: __________________ 

Address Line 2: __________________ 

City, State, ZIP code: __________________ 

An individual may revoke his/her consent at any time with a written request.

__________________                       ______________________

(Your Signature)                                            (Date)                     

__________________                       _______________________

(Your Address)                                      (Your Telephone Number)

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduc