Always send a completed, signed, and dated SSA-827.

Also send the standard hospital cover letter, except where the instructions require that an SSA-883-U3 be sent. (A computer-generated request for assistance letter may be used in lieu of an SSA-883-U3.)

Follow up with the appropriate contact person if evidence is not received within 30 calendar days from the date of the request.

1. a. 

   For the John H. Stroger, Jr., Hospital of Cook County and the Cook County Hospital, send a standard request letter to:

   Bureau of Disability Determination Services
   ATTN: Medical Information Unit
   P.O. Box 19250
   Springfield, IL 62794-9250
2. b. 

   Enter the following information:

   • •

     Admission dates

     NOTE: Show at least the year of admission. Make note of admissions with unknown dates.

   • •

     Discharge dates

     NOTE: If the claimant is currently hospitalized, the hospital will not furnish a report.

   • •

     Inpatient or outpatient status

   • •

     Date of birth

   • •

     Name and address at the time of admission (if different from the present)

   • •

     Hospital unit name, if known

   • •

     Patient's hospital unit number

     NOTE: The 6-digit hospital number (followed by a letter) is on any hospital identification card issued after January 1, 1969.

3. c. 

   After 30 days, follow up by telephone contact with the Medical Information Unit at (217) 785-5677.

   NOTE: Cook County Hospital, which provided in-patient care only, is now closed. These records are located in the same Medical Records Department that now services the new John H. Stroger, Jr., Hospital, which is in the same general location in Chicago. Please send all requests for records from either facility to the Medical Information Unit in the Illinois DDS.

NOTE: This instruction applies only to the main Duke University Hospital. Records requested from other Duke Hospitals should be addressed to the specific hospital, e.g., Duke Raleigh Hospital and Duke Regional Hospital.

1. a. 

   Send a standard request letter to:

   Duke University Medical Center
   Medical Records Release
   P.O. Box 3016
   Durham, NC 27710
2. b. 

   Include:

   • •

     Patient's full name

   • •

     Date of birth

   • •

     Parents' names

   • •

     Dates of treatment

   • •

     History number (see the patient's hospital/clinic ID card).

3. c. 

   Be sure the SSA-827 is dated within 90 days of receipt by Duke.

   NOTE: If signed by someone other than the patient, explain why in the request.

4. d. 

   Send an authorization for payment for $15 to the center.

1. a. 

   For the Fantus Health Center, send the standard request letter to:

   Bureau of Disability Determination Services
   Attn: Medical Information Unit
   P.O. Box 19250
   Springfield, IL 62794-9250
2. b. 

   Enter the following information:

   • •

     Claimant’s name and address

   • •

     Date of birth

   • •

     Date of first clinic visit

   • •

     Date of last clinic visit (include the word “outpatient”)

   • •

     Name and address at time of last visit (if different from present)

   • •

     Clinic or unit number (e.g., clinic number 70-62498; unit number - 421377).

3. c. 

   After 30 days, follow up by telephone with the Medical Information Unit at (217) 785-5677.

   NOTE: Send all requests for records from Fantus Health Center, Chicago, to the Medical Information Unit in the Illinois DDS.

Send out-of-State requests using a standard request letter to:

1. a. 

   Send a standard request letter to:

   Simtek
   Medical Records Section
   Hennepin County Medical Center
   701 Park Avenue South
   Minneapolis, MN 55415
2. b. 

   Include:

   • •

     Patient's full name

   • •

     Dates of treatment

   • •

     Hospital admission number

   • •

     Alleged impairment.

1. a. 

   Send a standard request letter to:

   Johns Hopkins Hospital
   Medical Information Section
   Department of Medical Records and Statistics
   600 N. Wolfe Street
   Baltimore, MD 21287-1015
2. b. 

   Include the following information:

   • •

     Full name of patient

   • •

     Hospital number

   • •

     Date of birth

   • •

     Sex

   • •

     Attending physician’s name

   • •

     Date(s) of hospitalization or treatment.

1. a. 

   Send a standard request letter to:

   Correspondence Department
   Massachusetts General Hospital
   121 Inner Belt Road
   Somerville, MA 022143-4453
2. b. 

   Include hospital record number (also known as patient identification number and the patient unit number) located on the blue patient card (also referred to as the ID, hospital card, or plastic card). If unavailable, also provide:

   • •

     Full name and address at time of admission (if different from present)

   • •

     Date of birth

   • •

     Dates of admission and discharge

   • •

     Name of claimant’s medical source(s).

NOTE: For information about impairments of the eye, ear, nose, and throat, send the request to the Massachusetts Eye and Ear Infirmary.

1. a. 

   Send a standard request letter to:

   Massachusetts Eye and Ear Infirmary
   Attn: Medical Records Correspondence Office
   243 Charles Street
   Boston, MA 02114
2. b. 

   Include:

   • •

     Hospital record number. If the hospital record number is unknown, provide the billing account number, if it is available.

   • •

     Full name and address at time of admission (if different from present)

   • •

     Date of birth

   • •

     Dates of admission and discharge

   • •

     Name of claimant’s medical source(s).

3. c. 

   If the claimant has been examined or treated in both, the hospital and the infirmary, send two separate requests.

1. a. 

   Send a standard request letter to:

   Mayo Foundation
   200 1st Street SW
   Attention: 201 Building TO-02-20
   Rochester, MN 55905
2. b. 

   Include:

   • •

     Name and address of requesting office

   • •

     Date of request

   • •

     Claimant's name and address

   • •

     Mayo Clinic number

   • •

     Alleged onset date

   • •

     Date of birth

   • •

     Date of most recent examination

   • •

     Social Security number

   • •

     Alleged impairment(s)

   • •

     All remaining medical entries to include specific dates, as pertinent

   • •

     DDS contact and telephone number.

3. c. 

   FAX any MER request, if applicable, to (507) 266-0447. Faxes may be sent in care of Lisa or Carey.

4. d. 

   Send all requests for medical records from Rochester Methodist Hospital and St. Mary's Hospital to the address in DI 22505.025B.9.a. Only one form is needed to request medical evidence from Mayo. Only one form is necessary if the claimant was seen at Mayo, St. Mary's and Rochester. The three facilities are considered the same for MER purposes. There is only one set of medical records for these facilities.

5. e. 

   Send one request only to the address in a. above if the claimant has listed both the Mayo Clinic and a separate medical source (e.g., a physician) at the Mayo Clinic as MER sources on the SSA-3368-BK or SSA-3820-BK.

6. f. 

   MER requests are processed by SourceCorp. If any problems are encountered with a request, their on-site supervisor is Mary Connor, (507) 284-2750.

1. a. 

   For the Puerto Rico Medical Center, send a standard request letter to:

   Administración de Servicios Médicos de Puerto Rico
   P.O. Box 2129
   San Juan, PR 00922-2129

   Atención: Hospital ­­­­­­­­­­­­­­­­­­­­_________________________
2. b. 

   Because this medical center is a complex of hospitals such as the University Hospital, Oncologic Hospital, Children’s Hospital, San Juan Municipal Hospital, Industrial Hospital, Centro Cardiovascular del Caribe, Psychiatric Hospital, include:

   • •

     Claimant's complete name, including both surnames (e.g., Ortega-Gasset)

   • •

     Date of birth

   • •

     Place of birth

   • •

     Social Security number

   • •

     Medical record number (usually 8 or 9 digits)

   • •

     Division where treated (e.g., mental, oncological, etc.)

   • •

     Type of treatment (e.g., inpatient or outpatient)

   • •

     Dates of treatment

   • •

     Allegations

   • •

     Claimant's address at time of treatment while living in Puerto Rico

   • •

     Onset date

   • •

     Claimant's father's name and mother's maiden name.

1. a. 

   District of Columbia DDS: Use the three-part Saint Elizabeth's Hospital request only when the patient is now an outpatient or inpatient. Include:

   • •

     Claimant's name and aliases

   • •

     Social Security number

   • •

     Date of birth

   • •

     Inpatient treatment dates

   • •

     Outpatient treatment dates

   • •

     Alleged onset date

   • •

     Specific testing

   • •

     Patient number, if available

   • •

     Name of treatment team

   • •

     Level of claim being filed, such as title II CDR, title XVI initial claim

   • •

     Any other available identifying information.

2. b. 

   Other DDSs: Use the standard request letter addressed to:

   Department of Mental Health
   Medical Records Section
   St. Elizabeth's Hospital
   2700 Martin Luther King, Jr. Avenue, S.E.
   Washington, D.C. 20032

   • •

     Contact the DC DDS Medical Relations Office (202-442-8516) for assistance in obtaining outpatient records through the above procedures.

   • •

     The hospital will request records prior to 1982 (in the Federal Records Center, Suitland, MD). Response time is 60 - 90 calendar days.

3. c. 

   All DDSs (DI 22505.025B.11.a. and DI 22505.025B.11.b.):

   NOTE: Do not send requests directly to physicians. Make telephone contacts if you want to communicate with treatment team members. The hospital will refer the telephone reports prepared by the DDS to the team member for signature.

1. a. 

   Send an SSA-883-U3 to:

   Bureau of Disability Determination Services
   Attn: Medical Information Unit
   P.O. Box 19250
   Springfield, IL 62794-9250
2. b. 

   Include:

   • •

     Claimant’s name and address

   • •

     Date of birth

   • •

     Date of first clinic visit

   • •

     Date of last clinic visit (include the word “outpatient”)

   • •

     Name and address at time of last visit (if different from present)

   • •

     Clinic or unit number, if available (e.g., clinic number 70-62498; unit number - 421377).

3. c. 

   After 30 days, follow up by telephone contact with the Medical Information Unit at (217) 785-5677.