AGENCY
LETTERHEAD
Date:
_______________
Case
ID: [Fill-in]
Addressee Name
Address Line 1
Address Line 2
City, State, ZIP Code
MEDICAL APPOINTMENT NOTICE
Dear [First Name] [Last name],
We are the office that makes decisions for Social Security. We made a medical appointment
for you because we need more information about your medical condition for your Social
Security disability claim. We will pay for this appointment.
Your Medical Appointment Information
|
Name and Address
|
Phone Number
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Date and Time
|
Type of Appointment*
|
*The medical evaluator may decide not to do some of the tests we ordered or that other
tests are needed.
Please arrive at your appointment 15 minutes early. If you are late, the medical evaluator may choose not to see you.
What you should bring to the appointment
Bring this letter and personal identification (e.g., U.S. State-issued driver’s license
or non-driver identity card, U.S. passport, U.S. military ID, student or school ID).
Bring any medications that you take in their original containers. Also, bring your
hearing aids, eyeglasses, contact lenses, canes, or other medical aids if you use
them.
What you should do next
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•
Confirm that you will attend your appointment. Please complete the enclosed response
form and mail it in the pre-addressed envelope provided. (Use the second sentence, only if you enclose a response form.) You should respond to our office within ten days of the date on this letter.
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•
Let us know if you cannot attend your appointment, as scheduled. Please call our office
immediately if you cannot attend your appointment for any reason. If you cannot attend
your scheduled appointment, and you would like us to reschedule, you must give us
a good reason.
If you have any questions or need assistance for the appointment
Contact us if you need help to pay for travel expenses to the appointment. We will
only consider payment of these costs if you ask us promptly. Normally, we reimburse
approved expenses after you attend the appointment. However, we will consider your
request for advance payment if you show us that the request is reasonable and necessary.
Also, call us if you need to request special arrangements for this medical evaluation
because you have a health issue that makes traveling difficult.
Let us know if you need a foreign language interpreter, a sign language interpreter,
or other assistance to communicate effectively with the medical evaluator. We will
arrange for interpreter services at no cost to you.
If you want a copy of the report sent to your doctor
If you want a copy of the report from this medical evaluation sent to your doctor,
please provide his or her full name and address. Please complete the enclosed authorization
form. (Use this statement only if you enclose an authorization form.)
If you miss the scheduled appointment
If you do not attend your appointment, we may make a decision based on the evidence
we already have in your file. We may find that you are not eligible or no longer eligible
for disability benefits. Please read the enclosed leaflet that explains more about
the consultative examination and your responsibility for attending.
If you have any questions about this letter or need to contact us about the appointment,
call Monday-Friday between 8:00 a.m. and 4:00 p.m. at the phone number below.
Thank you for your cooperation,
(NAME)__________________
(TITLE) __________________
PHONE NUMBER [Fill-in
TTY/TRS Fill-in
Enclosures:
SSA Publication No. 05-10087 (A Special Examination Is Needed for Your Disability
Claim)
Consultative Examination appointment confirmation form (List if enclosed.)
Authorization form (List if enclosed.)
SSA-5000 (Privacy Act Statement) (Enclose and list if you enclose the CE appointment confirmation form or authorization form.)