If you are unable to make telephone contact with the provider, send the SSA-4290-F5
to the provider with a signed and dated SSA-827 and a cover letter requesting their assistance using language similar to the following:
(Name of beneficiary)reports that they are receiving (vocational
rehabilitation services, employment services, educational services, or support services) from your organization. We need your assistance to determine if this beneficiary
can continue to receive disability benefits based on their participation in your program
and services. Please complete Part II, Section (A, B, C, or D, depending on the service
provider) of the enclosed form, sign it and return it to us within 10 days. If (name
of beneficiary) was participating in your program but stopped, please provide the
date that participation ended. Enclosed is a postage-paid return envelope. If you have any questions, please call (contact name and phone
number).
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Establish a 15-day diary on the CDR development worksheet (CDRW) of the DCF or SSI
development worksheet for return of the SSA-4290-F5.
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Make a follow-up contact with the service provider by phone, if the provider does
not return the SSA-4290-F5 within 15 days. Document all contact attempts on an SSA-5002
(Report of Contact) and fax it into eView.
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If you do not receive the completed SSA-4290-F5 within 30 days, upload the incomplete
SSA-4290-F5 into eView and transmit it, along with the Potential Section 301 Case
Flag, to the Office of Disability Operations' (ODO) Paperless Processing Center (PPC)
using the Evidence Portal's (EP) 4290 Barcode. Select the "Yes" on the Document Information
screen, to make the transmission actionable when PC involvement is required.