Effective Dates: 10/11/2024 - Present Previous | Next

TN 46 (10-24)

DI 22510.065 Sending the Consultative Examination Report to the Claimant's Medical Source - With Consent

A. Policy for sending the consultative examination (CE) report to a medical source

When the claimant has given consent, send a copy of the CE report to the claimant's medical source.

Also, see:

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    DI 81001.030B.2 for information on when a claimant or representative requests a copy of the CE report.

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    GN 03340.035D for information on when a parent or legal guardian requests a copy of the CE report for a minor child.

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    GN 03305.005C4 for restrictions on parental disclosure of a minor child's CE report.

B. Procedure for obtaining consent to release the CE report to a medical source

The DDS provides written notice of a CE appointment which includes an explanation that the DDS will send a copy of the CE report to the claimant's medical source when the claimant provides written authorization (see DI 22510.016B). Generally, the DDS includes the Authorization to Release CE Report Form (see NL 00705.745) with the CE Appointment Notice.

The returned Authorization to Release CE Report Form is considered completed when:

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    It is signed, dated, and received within 90 days of the signature date,

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    It includes the first and last name of the person or entity to whom the CE report should be released, and

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    It includes the address of the person or entity to whom the CE report should be released.

IMPORTANT: This form is only used to release a CE report to a claimant's medical source (or entity (i.e., organization) that maintains the medical source's records). If the person or entity listed on the authorization form is a nonmedical source (e.g., third party or educational source), handle as a claimant disclosure in accordance with GN 03305.001.

C. Procedure for releasing the CE report to the medical source

Follow the steps below when releasing the CE report, with a cover letter, to the claimant's medical source. For cover letter model language, see NL 00705.753.

1. Claimant attends CE and returns completed authorization form

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    Release the CE report to the claimant's medical source.

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    Explain in a cover letter that the report is being sent at the request of the claimant.

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    Include a copy of the cover letter to the medical source in Section E (Disability Related Development (Blue)) of the disability folder and document the Case Development Worksheet (CDW) in the Disability Case Processing System (DCPS) that a copy of the CE report was sent to the claimant's medical source.

NOTE: Do not delay adjudication when development is required per DI 22510.065C.1 in this section. If the case is ready for adjudication, close it and release the CE report after the authorization is received.

2. Claimant attends CE and returns incomplete authorization form or telephones about authorization form

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    Request a new, fully completed and signed authorization form from the claimant prior to releasing the CE report.

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    If the claimant returns a fully completed and signed authorization form, include it in Section E (Disability Related Development (Blue)) of the disability folder. Follow the instructions in DI 22510.065C.1 in this section.

NOTE: Do not delay adjudication when development is required per DI 22510.065C.2 in this section. If the case is ready for adjudication, close it and release the CE report after the authorization is received.

3. Claimant attends CE and does not return authorization form

Take no further action. However, if the CE report discloses new information that reveals a potentially life-threatening situation, follow the instructions in DI 22510.020A.4, DI 22510.070 and GN 03316.135.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510065
DI 22510.065 - Sending the Consultative Examination Report to the Claimant's Medical Source - With Consent - 10/11/2024
Batch run: 10/23/2024
Rev:10/11/2024