To complete the medical evaluation of an electronic case, process the applicable medical evaluation eForm(s) electronically through the Disability Determination Services (DDS) case processing system . The Disability Examiner (DE), the MC, or the PC prepares the impairment assessment eForm(s). The MC or PC must sign all impairment assessments. Prepare the following forms electronically using eForms and save them to the CEF:

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  SSA-538 – Childhood Disability Examination Form (CDEF);

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  SSA-2506-BK – Psychiatric Review Technique Form (PRTF);

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  SSA-4734-F4 – Residual Functional Capacity (RFC) Assessment; and

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  SSA-4734-F4-SUP – Mental Residual Functional Capacity (MRFC) Assessment.

An eForm cannot be altered or modified once it has been uploaded into the CEF. If, due to additional evidence being received, or other reason, a change is needed to a medical assessment form already uploaded to the CEF (but before the case is closed by the DDS), the DDS may use an SSA-416, or similar eForm to record the change in the original medical assessment. After completing and uploading the SSA-416, or similar eForm, add a note to both documents in the “Case Documents” section of eView to cross refer each document to the other as follows:

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  For the Medical Assessment form - ‘See SSA-416 (or similar eForm) dated xx/xx/xx.’

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  For the SSA-416 (or similar eForm) – “Revises SSA-4734 (or appropriate medical assessment form) dated xx/xx/xx.”

NOTE: The SSA-416, or similar eForm can not be used to make a change to the SSA-538, a new SSA-538 must be created to reference the initial SSA-538. See DI 25230.001B.4. for more information SSA-538.

Images of tracings (electrocardiogram, pulmonary function study tracings, etc.) are acceptable to use for medical evaluation, even if the image somewhat distorts the actual scale, as long as the scale is displayed on the image and the grid lines are viewable. (See Electronic Case Documentation - DI 81020.065, for information about scanning the tracing into the CEF.)