Consultative Examination Appointment Notice

SOCIAL SECURITY ADMINISTRATION                                        

	Office of Medical and Vocational Expertise Post Office Box 32908 Baltimore, MD 21241-2908
{@CLMTADDR}	DATE: {@DATE} SSN: {CSSN} DOB: {CDOB}

The Social Security Administration is reviewing your medical eligibility for disability under the Social Security Act. We need more information to help decide whether the medical requirements for these benefits are met. Therefore, we have scheduled a special {SLAYDESC} for you. We will use the information from this examination/test along with other information we have to make a decision on your claim.

The examination/test is scheduled for: {@APPTDATE} at {@APPTTIME}.

PLACE:

{@VOADDR} PHONE: {@VOPHONE}

Please bring any medications prescribed for your condition. Also bring your eyeglasses and/or hearing aid if you wear them.

{@CLMTINST}
If you fail to notify us at least 3 days before the date of this examination/test that you cannot keep your appointment, we will make a decision on your claim based on the information in your file. This means that we may find that you are not disabled.

Please be on time for the examination. We will pay for the cost of the examination/test.

We can send a copy of the report to your doctor. If you wish to do this, complete the enclosed authorization form and return it to us at the address shown below.

The Social Security Administration can reimburse you for transportation and other travel related expenses to the consultative examination and/or tests. If you travel to the consultative examination or test by either a private vehicle or public transportation (bus, subway, or trolley), you should complete the enclosed “Travel Reimbursement Request” form after your examination or test and return it to us within 20 days. If it is necessary for you to pay a toll or for parking to attend your examination or test, please obtain receipts and forward them to us with your completed “Travel Reimbursement Request” form. There is no need to get advance approval for travel reimbursement from your Case Manager if you take a private vehicle or public transportation to the consultative examination or test.

If a private vehicle or public transportation is unavailable or impractical, you can take another form of transportation such as a taxi, medically equipped vehicle, train, etc. to your examination or test but you must get pre-approval from the Office of Medical and Vocational Expertise. You should call your Case Manager at the number listed below to obtain pre-approval for travel expenses. Once you have obtained pre-approval and traveled to the consultative examination or test, you should complete, sign and return the enclosed “Travel Reimbursement Request” form and send it with the appropriate receipts to the address listed below. You should always make copies of your receipts and the “Travel Reimbursement Request” form for your records. If you have any questions, or need pre-approval for travel reimbursement, please call 1-800-582-{PALTPHONE4} Extension: {PALTEXT} (toll free).

Return to:

Social Security Administration
Office of Medical and Vocational Expertise

Attn: {PFIRSTNAME} {PLASTNAME}
Post Office Box 32908

Baltimore, MD 21241-2908

If you have questions about your claim, you can call us at the toll free number below.


{PFIRSTNAME} {PLASTNAME}
Case Manager
1-800-582-{PALTPHONE4}
Extension: {PALTEXT} (toll free)

Enclosures:
Pub 05-10087
Authorization to Release Medical Report to Physician
Travel Reimbursement Request Form
Preaddressed Mailing Envelope

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