TN 26 (03-24)

NL 00705.770 Letter Requesting Medical Evidence of Record

 

AGENCY

LETTERHEAD

Date: [Fill-in

Case ID: Fill-in

Addressee Name

Address Line 1

Address Line 2

City, State, Zip Code

 

RE: Claimant Full Name

AKA: AKA Name

DOB: DOB

Vendor Number: Vendor Number

 

We are the office that makes disability decisions for the Social Security Administration. Claimant's full name is applying for or is receiving disability benefits due to the following conditions: allegations. This is not an authorization to perform an examination.

What We Need From You

To help us evaluate this claim, please send records covering the period of: start date to end date

Free form text

MER special instructions

Include the following information: medical history, psychiatric history, clinical findings, laboratory findings, imaging reports, pathology reports, treatment prescribed and the response, diagnosis, and prognosis.

Please respond by MER Return Date. We are enclosing a signed HIPAA compliant authorization for the release of medical records and information.

If adult

Please provide a statement based on your findings. Your statement should express your opinion about your patient's ability to do work-related physical and/or mental activities despite the limitations or restrictions imposed by their medical condition(s). For physical impairments, these activities include sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical activities (including manipulative or postural activities, such as reaching, handling, stooping, or crouching); other activities, such as seeing, hearing, or using other senses; and ability to adapt to environmental conditions, such as temperature extremes or fumes. For mental impairments, these activities include understanding; remembering; maintaining concentration, persistence, or pace; carrying out instructions; and responding appropriately to supervision, coworkers, and work pressures.

If child

Please provide a statement based on your findings. Your statement should express your opinion about your patient's abilities and limitations or restrictions compared with children of the same age who do not have medical condition(s). Consider areas such as acquiring and using information; attending and completing tasks; interacting and relating with others; moving about and manipulating objects; caring for themselves; and health and physical well-being. Please also comment on how this child's medical condition(s) and associated treatments, including the frequency of treatment, affect their overall functioning.

If it is determined that we need additional information regarding your patient's impairment(s), would you be willing to perform an examination to provide additional findings? Please contact us if you would be willing to perform this examination. We will assume that you do not wish to perform the examination if you do not respond.

If You Have Any Questions

If you have any questions or wish to provide more information, please call us at the number(s) shown below Monday-Friday local office hours. When you call or leave a message, please provide the Case ID: case ID, your name, First Name Last Name's name, and a call back number.

Thank you for your help,

 

[Name]

[Phone Number]

[Fax Number]

 

Enclosures:

Privacy Act and Paperwork Reduction Act Statements

Signed SSA-827 (Authorization To Disclose Information to the Social Security Administration (SSA))

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