TN 17 (12-11)

NL 00705.770 Model Letter Requesting Medical Evidence of Record (MER)

                                                                                                        ****BARCODE****

                                                           AGENCY

                                                        LETTERHEAD

                                                                                                         Date: _______________

                                                                                                        Claim ID: ___________

Addressee Name

Address Line 1

Address Line 2

City, State, ZIP Code

Claimant: [Fill-in]

DOB: xx/xx/xxxx

We are the office that makes disability determinations for Social Security. [First Name] [Last Name] is applying for or is receiving disability benefits due to the following conditions: [List Conditions]

Please provide medical evidence including the following information: medical history, clinical findings, laboratory findings, treatment prescribed and the response, diagnosis, and prognosis.

Please send the information requested below, covering the period of [Fill-in date] to [Fill-in date], to help us evaluate this claim.

  • [Fill-in] (e.g., history, diagnosis/prognosis, most recent mental status exam, etc.)

  • [Fill-in]

We are enclosing a signed HIPAA compliant authorization (SSA-827) for the release of medical records and information.

[Optional canned text for claims involving mental impairments]

Please provide a statement based on your findings. Your statement should express your opinion about your patient’s ability to do work-related mental activities despite the limitations imposed by his/her mental condition(s). These activities include: understanding, carrying out and remembering instructions, and responding appropriately to supervision, coworkers, and work pressures.

[Optional canned text for claims involving physical impairments]

Please provide a statement based on your findings. Your statement should express your opinion about your patient’s ability to do work-related physical activities despite the limitations imposed by his or her medical condition(s). These activities include sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.

[Optional canned text for a claim for a child]

Please provide a statement based on your findings. Your statement should express your opinion about your patient’s abilities and limitations compared with children of the same age without medical conditions. Consider areas such as, but not limited to, age-appropriate learning, attention, interaction with other people, motor functioning, and behavior and self-care. Please also comment on how this child’s medical condition(s) and associated treatments,