PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 225 – Case Development ProceduresSubchapter 05 – Development of Medical Evidence of Record (MER)Transmittal No. 26, 10/24/2019
This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.
Summary of Changes
DI 22505.025 Developing Evidence from Medical Sources of National Significance
Including a note that John Hopkins Hospital and Mayo Clinic are HIT partners.
Follow these instructions to develop evidence from medical sources of national significance.
Always send a completed, signed, and dated SSA-827.
Also send the standard hospital cover letter, except where the instructions require that an SSA-883-U3 be sent. (A computer-generated request for assistance letter may be used in lieu of an SSA-883-U3.)
Follow up with the appropriate contact person if evidence is not received within 30 calendar days from the date of the request.
Follow the instructions below to develop medical evidence from the identified hospitals.
For the John H. Stroger, Jr., Hospital of Cook County and the Cook County Hospital, send a standard request letter to:
Enter the following information:
NOTE: Show at least the year of admission. Make note of admissions with unknown dates.
NOTE: If the claimant is currently hospitalized, the hospital will not furnish a report.
Inpatient or outpatient status
Date of birth
Name and address at the time of admission (if different from the present)
Hospital unit name, if known
Patient's hospital unit number
NOTE: The 6-digit hospital number (followed by a letter) is on any hospital identification card issued after January 1, 1969.
After 30 days, follow up by telephone contact with the Medical Information Unit at (217) 785-5677.
NOTE: Cook County Hospital, which provided in-patient care only, is now closed. These records are located in the same Medical Records Department that now services the new John H. Stroger, Jr., Hospital, which is in the same general location in Chicago. Please send all requests for records from either facility to the Medical Information Unit in the Illinois DDS.
NOTE: This instruction applies only to the main Duke University Hospital. Records requested from other Duke Hospitals should be addressed to the specific hospital, e.g., Duke Raleigh Hospital and Duke Regional Hospital.
Send a standard request letter to:
Patient's full name
Dates of treatment
History number (see the patient's hospital/clinic ID card).
Be sure the SSA-827 is dated within 90 days of receipt by Duke.
NOTE: If signed by someone other than the patient, explain why in the request.
Send an authorization for payment for $15 to the center.
For the Fantus Health Center, send the standard request letter to:
Claimant’s name and address
Date of first clinic visit
Date of last clinic visit (include the word “outpatient”)
Name and address at time of last visit (if different from present)
Clinic or unit number (e.g., clinic number 70-62498; unit number - 421377).
After 30 days, follow up by telephone with the Medical Information Unit at (217) 785-5677.
NOTE: Send all requests for records from Fantus Health Center, Chicago, to the Medical Information Unit in the Illinois DDS.
Send out-of-State requests using a standard request letter to:
Hospital admission number
Include the following information:
Full name of patient
Attending physician’s name
Date(s) of hospitalization or treatment.
Include hospital record number (also known as patient identification number and the patient unit number) located on the blue patient card (also referred to as the ID, hospital card, or plastic card). If unavailable, also provide:
Full name and address at time of admission (if different from present)
Dates of admission and discharge
Name of claimant’s medical source(s).
NOTE: For information about impairments of the eye, ear, nose, and throat, send the request to the Massachusetts Eye and Ear Infirmary.
Hospital record number. If the hospital record number is unknown, provide the billing account number, if it is available.
If the claimant has been examined or treated in both, the hospital and the infirmary, send two separate requests.
Name and address of requesting office
Date of request
Claimant's name and address
Mayo Clinic number
Alleged onset date
Date of most recent examination
Social Security number
All remaining medical entries to include specific dates, as pertinent
DDS contact and telephone number.
FAX any MER request, if applicable, to (507) 266-0447. Faxes may be sent in care of Lisa or Carey.
Send all requests for medical records from Rochester Methodist Hospital and St. Mary's Hospital to the address in DI 22505.025B.9.a. Only one form is needed to request medical evidence from Mayo. Only one form is necessary if the claimant was seen at Mayo, St. Mary's and Rochester. The three facilities are considered the same for MER purposes. There is only one set of medical records for these facilities.
Send one request only to the address in a. above if the claimant has listed both the Mayo Clinic and a separate medical source (e.g., a physician) at the Mayo Clinic as MER sources on the SSA-3368-BK or SSA-3820-BK.
MER requests are processed by SourceCorp. If any problems are encountered with a request, their on-site supervisor is Mary Connor, (507) 284-2750.
For the Puerto Rico Medical Center, send a standard request letter to:
Because this medical center is a complex of hospitals such as the University Hospital, Oncologic Hospital, Children’s Hospital, San Juan Municipal Hospital, Industrial Hospital, Centro Cardiovascular del Caribe, Psychiatric Hospital, include:
Claimant's complete name, including both surnames (e.g., Ortega-Gasset)
Place of birth
Medical record number (usually 8 or 9 digits)
Division where treated (e.g., mental, oncological, etc.)
Type of treatment (e.g., inpatient or outpatient)
Claimant's address at time of treatment while living in Puerto Rico
Claimant's father's name and mother's maiden name.
District of Columbia DDS: Use the three-part Saint Elizabeth's Hospital request only when the patient is now an outpatient or inpatient. Include:
Claimant's name and aliases
Inpatient treatment dates
Outpatient treatment dates
Patient number, if available
Name of treatment team
Level of claim being filed, such as title II CDR, title XVI initial claim
Any other available identifying information.
Other DDSs: Use the standard request letter addressed to:
Contact the DC DDS Medical Relations Office (202-442-8516) for assistance in obtaining outpatient records through the above procedures.
The hospital will request records prior to 1982 (in the Federal Records Center, Suitland, MD). Response time is 60 - 90 calendar days.
All DDSs (DI 22505.025B.11.a. and DI 22505.025B.11.b.):
NOTE: Do not send requests directly to physicians. Make telephone contacts if you want to communicate with treatment team members. The hospital will refer the telephone reports prepared by the DDS to the team member for signature.
Send an SSA-883-U3 to:
Clinic or unit number, if available (e.g., clinic number 70-62498; unit number - 421377).