In most cases, you do not need to speak directly to the medical source for evidence. An office secretary, office manager, receptionist, hospital medical records technician, or other person who has access to the claimant’s medical records may be able to provide the needed information. Call the source’s office and:

1. a. 

   Explain the need for the requested medical evidence.

2. b. 

   Determine whether the office can receive and send faxes.

   1. 1. 

      If the source can receive and send faxes:

      • •

        Fax the medical source the request for medical evidence, the invoice, and an SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)), if he or she has not already received one.

      • •

        Ask the medical source to fax the requested evidence back to the certified electronic folder (CEF), using the fax number for your region by placing the bar-coded cover sheet on top of the first page of the document to ensure accurate placement in the case file. For information on faxing documents into the CEF see DI 81010.090C.

        NOTE: It is not necessary for the source to fax the SSA-827.

   2. 2. 

      If the source cannot receive and send faxes, you may request and receive evidence by U.S. mail or other delivery services.

IMPORTANT: You are not required to send an SSA-795 to the source for signature if the supplemental contact produced no new evidence, or simply confirmed evidence already received. However, you must still document the supplemental contact.

If you need to speak directly with a medical source in order to complete a medical assessment, telephone contact is appropriate. If the medical source provides new and material evidence:

1. a. 

   Explain to the source that you will:

   • •

     document the information provided on form SSA-795 (Statement of Claimant or Other Person) for his or her review; and

   • •

     send it for his or her review, date, and signature.

2. b. 

   Document the information the medical source provides on form SSA-795.

3. c. 

   Request the medical source sign and return the completed form to document the file.

4. d. 

   Determine whether the office can receive and send faxes.

   1. 1. 

      If the office can receive and send faxes:

      • •

        Fax the medical source the SSA-795, and an SSA-827, if he or she has not already received one.

      • •

        Ask the medical source to fax the requested evidence back to the certified electronic folder (CEF), using the fax number for your region by placing the bar-coded cover sheet on top of the first page of the document to ensure accurate placement in the case file. For information on faxing documents into the CEF see DI 81010.090C. It is not necessary for the source to fax the SSA-827.

        EXCEPTION: For Electronic Disability Collect System (EDCS) exclusions ask the source to fax you the evidence directly.

   2. 2. 

      If the office cannot send and receive faxes, you may request and receive evidence by U.S. mail or other delivery services.

REMEMBER: Document all development actions using the Disability Case Processing System (DCPS). For electronic processing exclusions, document development in the case summary.

In the applicable blocks on the top of the SSA-795 enter all the following:

• •

  The claimant’s name and social security number.

• •

  The complete name of the person making the statement (i.e. the person to whom you are speaking) and their relationship to the claimant (e.g., Jane Jones, Dr. Smith’s office manager). Indicate the person’s medical credentials, if any.

The statement content begins after the established lead-in language, “Understanding that this statement is for the use of the Social Security Administration, I hereby certify that -.”

In the body of the SSA-795, document the evidentiary information provided. Use the person’s own words to the extent possible.

Explain who documented the telephone conversation and when.

Example of an administrative note: “This statement was initially provided to John Doe, State DDS by telephone on 01/21/2015.”

If you don’t have other acceptable medical evidence that addresses the issue(s), you must wait for a signed telephone report (SSA-795) to document a:

• •

  partially favorable allowance, or

• •

  denial.

For example, the medical evidence establishes that the claimant received hemodialysis while hospitalized subsequent to a traffic accident. There is no evidence regarding the necessity for chronic hemodialysis. To satisfy the requirements in Listing 6.03, you contact the source to confirm chronic kidney disease (CKD), current dialysis, and that dialysis will be ongoing. However, the source indicates that the claimant suffered acute kidney failure that resolved prior to discharge. Assessment of the claimant’s impairment(s) directs a durational denial. You must wait for the signed SSA-795 to document the issue of kidney failure.

You do not need to wait for the signed SSA-795 if the claim is a fully favorable allowance. Document the case file with the issue(s) that the signed SSA-795 resolves. Place the signed SSA-795 in the file post-adjudicatively.

For example, the medical evidence establishes that the claimant received hemodialysis while hospitalized subsequent to a traffic accident. There is no evidence regarding the necessity for chronic hemodialysis. To satisfy the requirements in Listing 6.03, you contact the source to confirm chronic kidney disease (CKD), current dialysis, and that dialysis will be ongoing. The source indicates that the claimant’s traumatic kidney failure did not resolve. The claimant is currently receiving dialysis, and the source opines the need for chronic hemodialysis or transplant. If the established onset date (EOD) is fully favorable, you do not need to wait for the signed SSA-795 that documents the issue of CKD and chronic hemodialysis.