If you are unable to make telephone contact, 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 he or she is receiving (vocational rehabilitation services or employment services educational services, or
support services) from your agency, organization, or institution. We need your assistance to determine
if this beneficiary can continue to receive disability benefits based on his or her
participation in your program or services. Please complete Part II, Section (A, B,
C, or D, depending on the service provider) of the enclosed form, sign and return
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).
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.
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 the attempts on an SSA-5002 and fax it and the incomplete SSA-4290-F5
into eView or Non-Disability Repository for Evidentiary Documents (NDRED) if you do
not receive the completed SSA-4290-F5 within 30 days.
Fax the Potential Section 301 Case Flag to the Office of Disability Operations’ (ODO) Paperless Processing Center (PPC) using
the paperless fax number 1-877-385-0643.