Italy generally requests medical evidence in a letter under the heading “Institute Nationale della Providenza Sociale”, “Certificato Medico” . The folder may also include a physician's report, questionnaires, and certifications of birth and marriage. To date, Italy has requested only general physical examinations, making it necessary for the examiner to determine from the information on the “Certificato Medico”, what examinations are needed. However, Italy has agreed to start using a standard form titled Request for Medical Examination or Medical Evidence. This form should provide more specific information about the evidence or examination needed. Although Italy has agreed to use the form, we are not certain when the form will be printed.

“Certificato Medico” (Mod. SS3). This form will provide the name and address of the individual, various work activities and a summary of the medical history, physical condition, system review, and diagnosis. (See Exhibit 2.)

“Relazione Medico Legale (SS4TP)”, “Referta Medico Legal (SS4)”, “Perizia Medica Dettagliata (Comunita Europee--E213)”. These forms are Italian medical questionnaires. Italy may occasionally submit one of these forms and it will appear untranslated in the folder. The forms may also be accompanied by a letter asking SSA to complete the form attached. The examiner should disregard any of the above forms. In our negotiations, the Italian agency has indicated they will accept our consultative reports in the style prepared.

Germany provides identifying information and indicates the type of medical evidence needed on the “D/USA 3”. Where a general physical examination is requested, Germany will usually complete item 3 of the “D/USA 3”. If special tests or examinations are needed, Germany will check the block marked “D/USA 6A” in item 2 of the “D/USA 3” and include the form with the “D /USA 3” when forwarding the request.

“D/USA 3” German transmittal request form. (See Exhibit 3.)

“D/USA 6A” Disability Liaison Form. A form used by Germany to request specific consultative examinations and tests. (See Exhibit 4.)

“D/USA 7” Consent Statement. A declaration of consent authorizing SSA to obtain medical reports from physicians and hospitals for Germany, and/or authorization for SSA to release to Germany medical information in SSA files. (See Exhibit 5.)

Although these instructions are temporary, the format will essentially serve as a model for the development of all foreign medical requests and the manner in which medical information will be exchanged with foreign countries. However, as we gain experience, and as requests are received from other countries, some changes in the instructions may be necessary to accommodate the specific requirements of certain foreign countries.