Identification Number:
EM-12004 REV 3
Intended Audience:All RCs/ARCs/ADs/DDSs/FOs/PSCs/
Originating Office:ORDP OISP
Title:New Procedures for Form SSA-1695 – Identifying Information for Possible Direct Payment of Authorized Fee
Type:EM - Emergency Messages
Program:All Programs
Link To Reference:See References at the end of this EM.
Retention Date: Jan 19, 2018

Retention Date: December 19, 2016
Retention Date: May 18, 2016
Revised Retention Date: May 18, 2015
Retention Date: February 28, 2015
Retention Date: August 29, 2014

REVISION: 11/18/2014 – We revise EM 12004 REV 3 to clarify that our recent revision to the EM was to bring the document up to date to reflect current practice. There is no change in the barcode we use for the SSA-1695. Technicians should continue to use the SSA-1695 fax coversheet as they have been.

A. Purpose

This emergency message (EM) revises policy and procedure for the SSA-1695 (Identifying Information for Possible Direct Payment of Authorized Fees). SSA will no longer destroy the form after processing it. This message also includes an important reminder for DDS and all ODAR offices.
This EM is a revision of EM 12004 REV issued on 03/02/2012.

B. Background

To avoid accidental publication of a representative’s personal identifiable information (PII) (i.e., his or her SSN), we previously prohibited filing the SSA-1695 in the claim file (electronic or paper). The representatives also wanted confirmation that we had processed their forms and so we developed an acknowledgement letter (not to be confused with the SSA-L1697) to send to them once we input the SSA-1695. Due to continuing concerns expressed by representatives that we are not always processing their forms, we are now revising this policy.

C. New procedures

When the DDS or ODAR receives an SSA-1695:
      • DDS and ODAR offices do not process Form SSA-1695s.
      • These offices must send the SSA-1695 immediately to the claimant’s servicing FO for processing.
2. When the FO or PC receives an SSA-1695:
      a. Verify that a valid appointment exists and that SSA has not already effectuated a favorable decision.
      NOTE: Refer to GN 03920.055 if the representative timely submitted an SSA-1695, but we inadvertently released the withheld past-due benefits.
      b. Enter the information in POTS (#27 on the SSA menu) in the Appointed Representative Direct Payment Screens. For concurrent claims, input data for both Title II and Title XVI. Verify that your inputs post to the records.
      c. After keying the SSA-1695 into the system, use a black marker
      to mask the representative’s SSN completely. This step is critical.
      d. Annotate the upper right corner of the SSA-1695 with the word “Processed” along with the date you input the data into POTS.
      e. If the appointed representative
      did not provide an Employer Identification Number (EIN), write “Section Left Blank” across the EIN boxes to prevent future altering.
      f. Fax or file a copy of the SSA-1695. You
      must completely mask the representative’s SSN, per c. above, before faxing or filing the SSA-1695.

        · For electronic disability cases, after masking the representative’s SSN and marking the form “processed”, fax the form into the Jurisdictional Docs and Notices (red) section B of the electronic folder (EF), following procedure in DI 81010.090 (FOs) and DI 80830.100 (PCs). Fax the SSA-1695 into the EF, using the SSA-1695, Identifying Information for Possible Direct Payment of Authorized Fees fax cover sheet. In the note section, annotate SSA-1695 (adding the representative’s name is optional).

        · For paper disability cases, after masking the representative’s SSN and marking the form “processed” file a photocopy of the form, in the red section of the Modular Disability Folder (MDF) paper in the claim file.

        · For non-disability cases, after masking the representative’s SSN and marking the form “processed” fax the form into the Non-Disability Repository for Evidentiary Documents (NDRED).

        · NOTE: Do not Fax the SSA-1695 into the PC’s Paperless Processing Center System (PPC) under any circumstances.

      g. Send (or fax) the SSA-1695, with the SSN masked and the “Processed” date noted, with the acknowledgement letter back to the representative.
3. If an “un-masked” (i.e., one showing the representative’s SSN) or “partially masked” (i.e., showing one or more digits of the SSN) SSA-1695 appears in the EF, follow directions DI 81010.090 (FOs) or DI 80830.100 (PCs) to:
      a. Move the un-masked or partially masked form to the current development/temp (green) section C in the EF;
      b. Print the SSA-1695;
      c. Mask the SSN; and
      d. Re-fax per section C.2.f. above.

4. If there is not SSA-1695 processed when the technician is ready to effectuate a favorable decision, but there is an SSA-1696 or written equivalent from a representative which requests direct fee payment, and the representative is eligible for direct fee payment, the technician must:
      • Contact the representative;
      • Inform the representative that SSA has not received the SSA-1695;
      • If the representative wants direct payment, instruct him or her to fax the SSA-1695 immediately.
        NOTE: You should try to establish the link before effectuating the claim.

Direct all program-related and technical questions to your RO support staff or PC OA staff. RO support staff or PC OA staff may refer questions or problems to their Central Office contacts.

DI 80630.010 Electronic Folder (EF)
DI 80640.020 Electronic Folder (EF)
DI 80650.050 Scanning
DI 80830.030 Using Information in the Electronic Folder (EF)
DI 80830.100 Barcodes
DI 80850.055 Barcodes
DI 80850.060 Scanning
DI 81010.090 Faxing Documents into the Certified Electronic Folder (CEF) Using Barcodes
GN 03910.042 Forms 1099-MISC and Employer Registration
GN 03920.017 Payment of Representative's Fee
GN 03920.055 Benefits Not Available to Certify Direct Payment to a Representative
EM-12004 REV 3 - New Procedures for Form SSA-1695 – Identifying Information for Possible Direct Payment of Authorized Fee - 11/18/2014