The Disability Determination Services (DDS) may receive CE reports through Electronic Records Express (ERE), by mail, or by facsimile (fax). If there is any question about whether the CE source transmitted a faxed CE report:

• •

  Contact the CE source to verify that they sent the CE report via fax; and

• •

  Document the contact in a Case Note in the Disability Case Processing System (DCPS) and "write to" the case development worksheet (CDW).

Review each CE report, including revised or corrected reports, for completeness and the following required information:

1. a. 

   Does the document properly identify the claimant as required by DI 22510.015B.1?

2. b. 

   Is the CE report complete?

   1. 1. 

      Were all the pages of the CE report received?

   2. 2. 

      Does it contain the information requested?

   3. 3. 

      Does it document evidence reviewed during the course of the appointment? See DI 22510.035B.1 and DI 22510.100B.1.

   4. 4. 

      Is it internally consistent?

      • •

        Are all the disorders, diseases, impairments, and complaints described in the history adequately assessed and reported in the clinical findings?

      • •

        Do the conclusions correlate with the findings from the medical history, the clinical examination, and the laboratory tests, and explain all abnormalities?

   5. 5. 

      Does the report address important or relevant complaints (within the scope of the requested exam) noted in other evidence in the file (e.g., blindness in one eye, amputations)?

3. c. 

   Did the CE source properly sign the CE report? For signature requirements, see DI 22510.015C.

4. d. 

   Did the CE source submit a copy of any records provided to them directly from the claimant at the examination (see DI 39542.240)?

If any of the required information in DI 22510.020B.2. in this section is missing or incomplete, contact the CE source to:

1. a. 

   Explain what is inadequate about the report; and

2. b. 

   Request the missing information or a revised and corrected report; and

3. c. 

   Document the contact in a Case Note in DCPS and "write to" the CDW.

1. a. 

   The DDS may release a copy of the CE report to the claimant's medical source if the claimant provides written consent. Follow procedures in DI 22510.065. For cover letter model language, see NL 00705.753.

2. b. 

   The DDS may release a copy of the CE report to the claimant's medical source without the claimant's consent if the CE report discloses new diagnostic information or test results that reveal a potentially life-threatening situation (i.e., an emergency, life or death situation where harm is believed to be imminent). In this situation, consent is not required. Follow procedures in DI 22510.070. For cover letter model language, see NL 00705.753.

3. c. 

   If the claimant does not have a medical source and the CE report indicates an emergency, life or death situation where harm is believed to be imminent, advise the claimant in a letter to see a health care provider for evaluation or treatment. If the claimant is unable to pay for such services, inform the claimant of any local agency or medical facility where they can obtain the medical services at limited or no cost. In addition to sending a letter to the claimant, the DDS should also attempt to contact the claimant by telephone to provide this information. For cover letter model language, see DI 22510.070. The DDS should refer to the language in DI 22510.070 when contacting the claimant by telephone.

If the CE report is unsigned or improperly signed and the determination is not fully favorable:

1. a. 

   Do not adjudicate or close the case. The DDS must wait until they receive a properly signed CE report.

2. b. 

   Document the attempts to obtain a properly signed report in a Case Note in DCPS and "write to" the CDW.

3. c. 

   If a properly signed report cannot be obtained from the CE source who originally performed the CE for any reason, the DDS must reschedule the CE with another qualified CE source (see DI 22510.010).

4. d. 

   The DDS includes the unsigned or improperly signed CE report in the disability folder (see DI 81020.070C).

If the CE report is unsigned or improperly signed and the determination is fully favorable:

1. a. 

   Document the attempts to obtain a properly signed CE report in a Case Note in DCPS and "write to" the CDW.

2. b. 

   Adjudicate and close the case.

3. c. 

   The DDS includes the properly signed CE report, obtained post adjudication, in Section F (Medical Records (Yellow Back)) of the disability folder.

4. d. 

   If the DDS does not obtain a properly signed CE report after the case has been adjudicated, contact the Regional Office for instructions.