TN 26 (03-24)
NL 00705.770 Letter Requesting Medical Evidence of Record
AGENCY
LETTERHEAD
Date: [Fill-in
Case ID: Fill-in
Addressee Name
Address Line 1
Address Line 2
City, State, Zip Code
RE: Claimant
Full
Name
AKA: AKA Name
DOB: DOB
Vendor Number: Vendor Number
We are the office that makes disability decisions for the Social Security Administration.
Claimant's
full
name is applying for or is receiving disability benefits due to the following conditions: allegations. This is not an authorization to perform an examination.
What We Need From You
To help us evaluate this claim, please send records covering the period of: start date to end
date
Free form text
MER special instructions
Include the following information: medical history, psychiatric history, clinical
findings, laboratory findings, imaging reports, pathology reports, treatment prescribed
and the response, diagnosis, and prognosis.
Please respond by MER Return Date. We are enclosing a signed HIPAA compliant authorization for the release of medical
records and information.
If adult
Please provide a statement based on your findings. Your statement should express your
opinion about your patient's ability to do work-related physical and/or mental activities
despite the limitations or restrictions imposed by their medical condition(s). For
physical impairments, these activities include sitting, standing, walking, lifting,
carrying, pushing, pulling, or other physical activities (including manipulative or
postural activities, such as reaching, handling, stooping, or crouching); other activities,
such as seeing, hearing, or using other senses; and ability to adapt to environmental
conditions, such as temperature extremes or fumes. For mental impairments, these activities
include understanding; remembering; maintaining concentration, persistence, or pace;
carrying out instructions; and responding appropriately to supervision, coworkers,
and work pressures.
If child
Please provide a statement based on your findings. Your statement should express your
opinion about your patient's abilities and limitations or restrictions compared with
children of the same age who do not have medical condition(s). Consider areas such
as acquiring and using information; attending and completing tasks; interacting and
relating with others; moving about and manipulating objects; caring for themselves;
and health and physical well-being. Please also comment on how this child's medical
condition(s) and associated treatments, including the frequency of treatment, affect
their overall functioning.
If it is determined that we need additional information regarding your patient's impairment(s),
would you be willing to perform an examination to provide additional findings? Please
contact us if you would be willing to perform this examination. We will assume that
you do not wish to perform the examination if you do not respond.
If You Have Any Questions
If you have any questions or wish to provide more information, please call us at the
number(s) shown below Monday-Friday local office hours. When you call or leave a message, please provide the Case ID: case ID, your name, First Name Last Name's name, and a call back number.
Thank you for your help,
[Name]
[Phone Number]
[Fax Number]
Enclosures:
Privacy Act and Paperwork Reduction Act Statements
Signed SSA-827 (Authorization To Disclose Information to the Social Security Administration
(SSA))
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