The DDS is required to recontact a medical source when:

• •

  The evidence in the file is incomplete, and the needed evidence is only available from this source; or

  EXAMPLE: The claimant has a consultation with a treating orthopedist and undergoes magnetic resonance imaging (MRI). The medical source only sends the physical examination report and not the MRI report.

• •

  The medical source provided evidence that contains an internal inconsistency, and it is unclear from the existing evidence whether the claimant is disabled.

  EXAMPLE: Medical records from the claimant's orthopedist show normal gait on exam, but the medical records also mention that the claimant uses a walker for ambulation. This internal inconsistency should be resolved by recontacting the source for clarification. If this recontact does not resolve the inconsistency, a consultative examination (CE) may be needed to resolve the issue. For more information on inconsistent evidence, see DI 24501.016B.4.

REMINDER: For situations when the DDS should not make routine requests, see DI 22505.006A.3.

Recontact a medical source by telephone, fax, or mail. Include an SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)), if needed.

1. 1. 

   To recontact a medical source by telephone, follow the procedures in DI 22505.030.

   REMINDER: The preferred method to recontact a medical source to request missing evidence or resolve inconsistencies is by telephone. After recontacting a medical source, it may be necessary to fax or mail additional letters to obtain the necessary information.

2. 2. 

   To recontact a medical source by fax or mail, send a letter explaining:

   • •

     The nature of the missing evidence or inconsistency;

   • •

     Why the DDS needs clarification; and

   • •

     The type of evidence needed.

3. 3. 

   Use follow-up procedures in DI 22505.035, if needed.

4. 4. 

   Stop follow-up procedures when the missing evidence is obtained, the inconsistency is resolved, or the medical source cannot or will not provide the requested information.

   EXAMPLE 1: The DDS receives a medical report from the claimant's nephrologist that references serum creatinine values above 4mg/dl over a period of several months. The medical report does not contain the actual lab reports. The medical report suggests that the claimant may meet listing 6.05A.1, but the lab reports are needed to make the determination. In this situation, the DDS should recontact the nephrologist by phone to explain what missing information is needed. If the nephrologist's office advises that the information will be sent without further action from the DDS, the DDS should document the conversation in the case file and set an appropriate follow-up date to receive the missing evidence. If the nephrologist's office asks the DDS for another evidence request, the DDS should fax or mail the request, along with an SSA-827, if needed, explaining what missing information is needed.

   EXAMPLE 2: The DDS receives a medical report from the claimant's orthopedist that references an x-ray showing degenerative disc disease. The medical report does not contain the x-ray report. The DDS needs the x-ray report to help establish the medically determinable impairment (MDI). The DDS attempts to recontact the orthopedist's office by phone and leaves a voicemail detailing what information is needed. The DDS does not receive a response to the voicemail. The DDS sends a request by mail with specific details about what information is needed. After waiting 10 days with no response to the phone call or mailed request, the DDS makes another phone call to follow-up on the mailed request and again leaves a voicemail that is not returned. At this point, the DDS should proceed with ordering a CE for an x-ray to obtain the missing information.

When updated evidence (e.g., from a follow-up medical exam, test, or procedure that has already taken place) is available from an existing medical source, and the evidence is relevant to the determination (see DI 24501.016B.2.), request the updated medical evidence. If the DDS does not receive the available medical evidence within 10-20 days follow standard follow-up procedures in DI 22505.035.

EXAMPLE 1: Helen alleged chronic obstructive pulmonary disease (COPD). The DDS requested medical evidence from Helen’s pulmonologist, which was received on 3/3/2021. On 3/8/2021, Helen called the DDS to report having a pulmonary function test (PFT) at the pulmonologist's office on 3/7/2021. In this situation, request the additional medical evidence from Helen’s office visit, to obtain the physical examination and the results and tracings from the PFT.

EXAMPLE 2: John alleges major depressive disorder and general anxiety. On the SSA-3373 (Function Report - Adult) John reports difficulty concentrating and following simple instructions. The DDS receives medical evidence from John’s psychiatrist on 7/15/2022 which shows the doctor prescribed Prozac and Cymbalta in November of 2021. After increased medication dosage over several months, examinations from February 2022 to July 2022 show that John is stable and has not experienced any breakthrough symptoms. The most recent exam is from 7/8/2022. The DDS sends the claim to the DDS psychological consultant (PC) for review on 7/18/2022 and the PC completes a mental residual functional capacity assessment form (MRFC) on 8/1/2022. There are no physical impairments to assess.

John calls the DDS on 8/3/2022 to report an upcoming psychiatric appointment on 8/31/2022. John explains that this appointment is a regularly scheduled medication check. The DDS confirms that John has not been to the emergency room, hospital, or psychiatrist since the last visit on 7/8/2022. The DDS already obtained all available and relevant evidence, which is consistent and complete enough to make a determination. The DDS makes the determination using the available MRFC.

When the DDS discovers a new medical source during case development and the evidence could be relevant to the determination, request the available medical evidence from that source. Include an SSA-827 when the sending the request. If the DDS does not receive the available medical evidence within 10-20 days, follow standard follow-up procedures in DI 22505.035.

EXAMPLE 1: Dr. Smith, a rheumatologist, treats Sam for fibromyalgia. Medical evidence from Dr. Smith identifies Dr. Jones, a pain management specialist, who also treats Sam for fibromyalgia. Sam did not identify Dr. Jones as a medical source on the SSA-3368-BK (Disability Report - Adult). Dr. Jones’ records are relevant to the determination because this medical source treated Sam for an alleged impairment. In this case, the DDS must request the medical evidence from Dr. Jones.

EXAMPLE 2: The medical evidence from Dr. Jones mentions that Sam recently saw Dr. Phillips. The evidence does not mention the condition for which Dr. Phillips treats Sam. The DDS contacts Sam to get more information about Dr. Phillips. Sam explains that Dr. Phillips is a dentist that they see every six months for routine cleanings. The DDS does not request medical evidence from Dr. Phillips because it is not relevant to the claim.

Request updated evidence, including diagnostic tests, from all sources the claimant identified and request any new evidence discovered during development for the alleged or documented impairment(s) during the applicable period (see DI 22505.001). Send the request by mail, fax, or electronic method.

Use the follow-up procedures described in DI 22505.035 if needed.

The claimant is usually the best source of information about their medical history, medical sources, functional limitations, and past work. Generally, the DDS should request this information from the claimant before considering development from supplemental sources. Consider requesting information from the claimant when:

• •

  There is an indication that the claimant has not identified, on the SSA-3368, all potential impairments or medical sources that may be relevant to the disability determination (see DI 24505.030).

• •

  The DDS needs work history information (see DI 25005.000, DI 25015.000, DI 22515.003, and DI 22515.010); or

• •

  The information the claimant provided about their functional limitations is inconsistent with other information in the file or needs clarification (see DI 22511.011 and DI 24501.021).

To request evidence or action from the claimant, follow the procedures in DI 22505.014. Contact the claimant, as discussed in DI 23007.005, by mail or telephone.

For more information about when the claimant fails to provide the requested evidence, take the necessary action, or attend a needed CE, see DI 22505.014 and DI 23007.000.