TN 29 (10-24)
NL 00705.753 Consultative Examination Report to Medical Source Cover Letter
AGENCY
LETTERHEAD
Date: Fill-in
Case ID: Fill-in
Addressee Name
Address Line 1
Address Line 2
City, State, Zip Code
RE: Claimant Full Name
AKA: AKA Name
DOB: DOB
We are the office that makes disability decisions for the Social Security Administration.
[Claimant's full name] is applying for or is receiving disability benefits due to their medical condition(s).
If claimant has a medical source - permission
granted:
[Claimant Full Name] has asked us to provide you a copy of the enclosed Social
Security consultative examination/test report.
If claimant has an emergency, life or death situation where
harm is believed to be
imminent:
URGENT: Review is needed as soon as possible for a potentially
life-threatening finding.
The Social Security consultative examination/test indicated a situation that
requires immediate medical evaluation and/or treatment.
NOTE: Notify the claimant if a copy of the CE report was sent to the medical source without
the claimant's permission. Include a copy of the letter to the claimant in Section
E (Disability Related Development (Blue)) of the disability folder. See GN 03316.135C and DI 22510.070.
If You Have Any Questions
If you have any questions or wish to provide more information, please call us at the
number(s) shown below Monday-Friday local office hours. When you call or leave a message, please provide the Case ID: case ID, your name, First Name Last Name's name, and a call back number.
Thank you for your help,
[Name]
[Phone Number]
[Fax Number]
Enclosures:
Copy of Consultative Examination Report