Follow the rules for evidence in GN 00301.015, GN 00301.050, GN 00301.095, and GN 00301.305. If the evidence appears amended or altered, question the evidence. Uncertified photocopies,
faxes, etc. received directly from the WC/PDB payer are acceptable evidence of WC
or PDB payments as long as there is no reason to question the validity of the information.
NOTE: The information obtained by direct access from WC carriers, state agencies, etc.,
with or without the NH’s consent, is a third party report. Therefore, advance notification
(due process) is required prior to making any adverse adjustment to claimants’ benefits
based solely on those records. See GN 03001.025 - Processing Third Party Reports and due process notices in NL 00703.511 - NL 00703.513.
The following are examples of evidence from outside sources that would provide proof
1. Form SSA-1709 (Request for Workers’ Compensation/Public Disability Benefit Information)
To obtain Form SSA-1709, see OS 15020.295.
If the agency objects to using the SSA-1709, use their form if it provides substantially
all of the information requested on the SSA-1709 as described in DI 52145.010.
2. Alternative verification
Use the following for verification of WC/PDB amounts:
Computer printout from State records
Documented direct phone contact with the WC/PDB payer.