Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)

Sample CE Forms

u t t e r to Vendor Rescheduling consultative btamination/~e~t
for M u l t
DDS LETTERHEAD
(Includes railing mddress)

DATE:
Doctor's Name
Addrese qlne 1
A d d m 6 6 Line 2
City, state zip

RE:

Claimantrs Name
Address Line 1
Address L h e 2
City, State Zip

AKA:

SSN:

DOB:

000-00-0000
)M/DD/YY

We had scheduled an appointment for a current axamination/test on
I c l a i a a m vith your office for ldate C
but the
rxamination/test was not performed. This letter is to confirm
that ve have rescheduled this appointment for Jdate & w.
Your report vill help us determine this claimant'c eligibility
for Social Security or Supplemental Security Income disability
benefits.

w,

M t e r the axamination, plmase prepare a narrative report
including history (obtained during your intervimw), a11 objective
findings, diagnosis, and prognosis. We vould also like t o have a
statement about the individual's ability, despite functional
limitations Imposed by the Impairment(s), to perforn vork-related
mctivities.
0

Physical work activities include sitting, standing, walking,
lifting, carrying, handling objects, hearing, speaking, and
traveling.

o

Mental vork activities include understanding and memory;
mustained concentration and -persistence; mocial interaction;
and adaptation.

Pl-se do not expreas an opinion about whether the c l a h n t is
di-led
or capable of vorking. This judgment frequently depends
bn nonmedical factors much a6 age, mducation, a n d vocational
mki118.
If additional tests arm needed for your mvaluation,yol~ mast
tmlmphone us at the number above for muthoriration &form such
*st6 are made. The claimant should not be billed for any
Bervices provided as a part of this urnmination.

'

I t is imperative that your medical report be in our office within
l o days after the examination date, as we are under a rigid time
limit t o compl~tecases without unnecessary delay.
(include State information, if no.d.4)

U t t e r to Vandor Regarding Consultative ExarinationfTest for
Child
DDS mmEm
(Includes railing addrum)
DATE :
Doctor 'l Name
Mdre66Lfne 1
Address tine 2
City, State Zip

RE:

Claimant's Name
Address Line 1
Address Line 2
City, State Zip

SSN:

000-00-0000

DOB:

WII/DD/YY

We had mcheduled an appointment for a current examination/test on
but the
vith your office for a t e C
examination/test was not performed. This letter is t o confirm
that ve have rescheduled this appointment for (pat
Your reporr rill help us determine this c l a i m a n t a i t y
for social Security or Supplemental Security Income disability
benefits.
After the examination, please-prepare a narrative report
including medical history (secured during your interview), all
objective findings, diagnosis, and prognosis. We vould also like
t o have a ~tatementabout how the child's impairment(s) and
related mylaptons affect his or her daily activitils and ability
t o perform age-appropriate activities.

.

Domains of development or functioning that ray be addressed are:
cognition; comuniation; rotor abilities; social abilities;
responsiveness to stimuli (in children from birth t o age 1);
perronalfbehavioral patterns (in children from age 1 t o age 18);
and concentration, persimtence, and pace in taskcompletion (in
children from ige 3 to age 1B).
ff additional tests are needed for your evaluation, you rust
trlephone us at the number above for authorization before much
+k are made. The childtm parent/guardian or o t h u person
Cuponsible for this child rhould not be b i l l d for m y muvices
provided as a part of this examination.
It is imperative that your n d i c a l report k in our office vithin
10 days after the examination date, as ve are mu a rigid time
limit t o complete canes vithout unnecescary dolay.
(include State information, if needed)

Cover U t t e r to Vendor Regarding Consultative
Exmination/Test Appointment for Adult
DDS Ll3TERHEAD

(Includes mailing address)
DATE :
Doctor's Name
Address Line 1
Ad&ese pine 2
City, State Zip

RE:

SSN:
DOB:

Claimant's Name
Address Line 1
Ad&eS6 Line 2
City, State Zip

000-00-0000
UII/DD/YY

We need a current examination/test of (claimant's name), as shown
on the enclosed authorization. We have scheduled the appointment
vith your office for Jdate L timd. Your report will help us
determine this claimant's eligibility for Social Security or
Supplemental Security Income disability benefits.
After the examination, please prepare a narrative report
including history (obtained during your interview), all objective
findings, diagnosis, and prognosis. We would also like to have a
statement about the individua18s ability, despite functional
limitatinns imposed by the impairment(s). t o perform vork-related
activities.
o

Physical vork activities include sitting, standing,
valking, lifting, carrying, handling objects, hearing,
s$eaking, and traveling.

o Hental work activities include understanding and memory;
sustained concentration and persistence; social interaction;
and adaptation.
Please do not express an opinion about whether the claimant is
disabled or capable of working. This judgment frequently depends
on nonmedical factors such as age, education and vocational
mkills.
ff additional tests are needed for your evaluation, you must
trlephone us at the number above for authorization k f o r e such
h u t s are made. 'The claimant should not be billod for any
memice6 provided as a part of this axamination.

It i r imperative t h a t your medical report be i n our office w i t h i n
1 0 days a f t e r t h e examination date, as we are under a f i g i d the
limit t o wmplete c a s e s without unnecessary delay.

(include S t a t e information, i f needed)

Cover Letter to Vendor Regarding Consultative
StxaminationfTest Appointment for Child
DDS LETTERHEAD
(Includes railing addruo)

DATE:
boctor'm "Name
M&~ss
Line 1
Address Line 2
city,,state zip

RE:

Clahant'm Name
Addreas Line 1
Address Line 2
City, State Zip

6SN:

000-00-0000

DOB:

IMfDDfYY

We need a current examination/test of the person named in the
enclosed authori~ation. We have mcheduled the appointment with
your office for (pate S timel. Your report will help us
determine this claimant's eligibility for Supplemental Security
Income disability benefits.
M t e r the examination, please prepare a narrative report
including medical history (secured during your interview), all
objective findings, diagnosis, and prognosis. We would also like
to have a statement about how the childto impairaent(s) and
related mymptoms affect his or her daily activities and ability
t o perform age-appropriate activities.
Domains of development or functioning that ray be addressed are:
cognition; communication; rotor abilities; social abilities;
responsiveness t o stimuli (in children from birth t o age 1);
personal/kehavioral patterns (in children from age 1 t o age 18);
and concentration, persistence, and pace in task completion (in
chileen from age 3 t o age 18).
If additional tests are needed for your evaluation, you must
telephone US at the number above for authorization before such
tests are made. The child's parentfquardian or other person
responsible for this child should not be billed for any eervices
provided as a part of this oxamination.
It Is imperative that your medical reportbe in our office within
day6 after the examination date, a s We are under a rigid time
limit t o complete cases without unnecessary delay.

20

(include State information, if n m d d )

-

Enclosure for cE Appointment Letter
Authorization for
Release of Consultative Examination/Test Report
Physician
of Choice

-

-

i

Claimant's

Name:

Claimant's

SSN:

I hereby authorize the release of a copy of the medical report of
my consultative examination or test conducted by:
Examining Doctor (6)

to:

-

(Name of Treating Physician)

-

(Address of Treating Physician)

I understand this authorization is valid for up t o 90 days,
unless revoked in writing by me.

- (Claimant Signature)
*

-

(Claimant Address)

(Date)

Optional Consultative mamination/Test C o n i f m a t i o n
Response Porm
DDS LEITERHW

(Includas mailing a d d r e s s )
Clairant's/Applicantts ~ame:

DATE :

Addrase L l n e 2

6SN:

a dress L i n e 1

C i t y , S t i t e Zip
ICXMINER :

P l e a s e check the proper box t o l e t us know vhether you plan t o
keep the examination o r t e s t appointment scheduled f o r you on
_/date & t i m e l .
-7

I will keep the appointment.

1

J

1

I

(

L

A

I cannot keep the appointment because
. .

Sign and mail t h i s form i n t h e enclosed envelope a s soon as
possible.
*

Your
=.e

Signature

Bureau of Disability Determination Services
~ u d r e yMcCrimon

Illinois Department of Rehabilitaiion !hvices

Dear Doctor
We have been informed that you may be interested in performing
consultative examinations for our Bureau.
To be included on our Panel of Conmultants, we must receive and review
your-curriculum vitae which should include the following:
Medical School and date of graduation.
Place and dates of residency training.
Social Security Number.
State Medlcsl Licenee Number or
Copy of State Medical Licsnme Certlf icate
Uhethsr Board Csrtified and include mpeciality.
Hoepital affiliations.
Dep~rtnentnamc and address of ury State of
Illinois personnel payroll(8) you .re on at
this time.
Individual Tax IdentiIication Number (Please complete
attached Tax Ideatificatlon Number Form.)
Corporate or group Tax Identification Number
if you use one for a group practice.
Place and dnte of birth
ECFMG & if forelgn medical graduate
Encloeed with this letter 1 8 information regarding the dieclosure of
medical information under the Federal Privacy Act of 1974. Our Bureau
is currently required to obtain a wrltten acknowledgement of the
responslbillty of confidentinllty from a11 persons who perform
conmultative examinations. You will also find tbe Licensa/Credentials
krtification statement for your signature.

The 1 ~ l n o i oPurchaeing ~ c prohibitr
t
State employees from receivina
money for goods or services In a contract matisfied by paymmnt of
funds mpproprlated by the Illinoim Gsneral Aseembly. University
employees are excepted.

The current fee schedule has been enclosed for your information m d

-

future use.
Pleame forward to us your curriculum vitae and your signed Medical
Dimclosure Acknowledgement form. Your mpplication vill then..be given
every consideration by the Credentialr, Committee.
Very truly youre,

Edward C . Ference, M.D.
Chief Medical Conmultmt
EGF I DR; :rt
Enclosursa:

Federal Privacy Act Informational Sheet
Medical Dimclosure Acknowledgement/
License/Credentials Certification
Tax Identification Number Form
Fee Schedule
Envelope

1

Dear
We have been informed that several of your physicians in your group
might be interested in performing coneultative examinntione for our
Bureau.
To be included on our Panel of Conaultatits, we muet receive and review
each proepective pmtliet'm curriculum vitae. Theme curricula vitae
rrhould Include the follouing:
Medical School and date of graduation.
Place and datem of remidency training.
Social Security Number.
State Medical Llcenme Number.
Whether Board Certified and include speciality.
Hospital affiliations.
Department name and addreso of any State of
Illinoim personnel payroll(6) you are on at
thin time.
Individual Tax Identification Number (Please complete
attached Tax Identification Number Form.)
Corporate or group Tax Identification Numbar
_ i f one ie used for a group practice.
Place and date of birth
ECIMG # if foreign medical graduate
Enclosed with t h i e letter is information regarding the disclosure of
medical information under the Federal Privacy Act of 1974. Our Bureau
im currently required to obtain a written acknowledgement of the
responsibility for confidentiality from all permona who perform
conmultative examinations. Therefore, please reguest each of the
doctors to read all of the information carefully and for each to eign
one of the Medical Disclomure Acknovltdgmtnt forms m d the Lieenme/
Credentials Certificstion statement onclomed.

I

*The Illinois Purchasing Act prohibite State employeem from receiving
money for goods or eervices in a contract satiofied by payment of funds
appropriated by the I l l i n o i ~General Assembly. University employeee are
excepted.

-.

Please forward to us the curricula vitae and the mimed Medical
Dimclosure Acknowledgement fonne. These applications will than be
given every consideration by the Credentials Committee.

Very truly yourm,

Edvard C. Ference, M.D.
Chief Medical Conmultant

Enclosures:

Federal Privacy Act Information Sheet
Medical Dimclosure Acknowledgement/
Licen~e/Credential~Certification
Tax Identification Munbcr Form
Fee Schedule
Envelope

Bureau of Disability Determination Services
Illinois Department of Rehabilitatioi Services

Dear Doctor
We hmve been informed t h a t you may'be i n t e r e e t e d i n pbrforming
c o n s u l t a ' t i v e examinations f o r our Bureau.
To b e i n c l u d e d on our Panel of Consultants, w e must r e c e i v e md review
your curriculum v i t a e which should i n c l u d e the following:
1. School and d a t e of graduation.
2 . S o c i a l S e c u r i t y Number.
3. R e g i s t r a t i o n Number.
4. Hospital a f f i l i a t i o n s .
5 . Department name and addrbslr of any S t a t e o f
I l l i n o i s pereonnel p
a r e on a t
- a -y r o l l ( 8 ) you
t h i e time, *
6 ., I n d i v i d u a l Tax I d e n t i f i c a t i o n Number (Plmase complete
a t t a c h e d Tax I d e n t i f i c a t i o n Number Form.)
7 . Corporate o r Group T u I d e n t i f i c a t i o n Number
if you use one f o r a group p r a c t i c e .

Encloeed vlth t h i s l e t t e r i s information r e g a r d i n g t h e dimclomure of
medical i n f o r m a t i o n undor t h e F e d e r a l P r i v a c y A c t of 1974. Our Bureau
i s c u r r e n t l y r e q u i r e d t o o b t a i n a writtmn acknowlbdgement of t h e
r e s p o n s i b i l i t y o f c o n f i d e n t i a l i t y from a11 persons who perform
c o n l r u l t a t i v e examinations. You w i l l a l s o f i n d t h e License/
C r e d e n t i a l 6 C e r t i f i c a t i o n statbment f o r your e i g n a t u r e .
A copy of' t h e c u r r e n t f e e echedule h a s been encloeed f o r your
i n f o r m a t i o n and f u t u r e use.

*The I l l i n o i s Purchasing Act p r o h i b i t s S t a t e employees from r e c e i v i n g
money f o r goods o r servicem in a c o n t r a c t s a t i s f i e d by payment of f u n d s
a p p r o p r i a t e d b y the I l l i n o i s General Assembly. U n i v e r s i t y employees
a r e excepted.

,-.

Please forward to us your curriculum vitae m d your signed Medical
Dlscloeura Acknowledgment £ o m . Your application will then be given
ovary consideration by the Credantials Committee.

Edward C. Ference, M.D.
Chief Medical Consultant

Encloeuree:

Federal Privacy k t Information Sheet
Medical Dieclosure Acknowladgement
Licenme/Credentials Cartificetion
Tax Idcntificatlon Number Porn
Fee Schedule
Envelope

Bureau of Disability Determination Services
I

Audrey McCrimon

Illinois Department of Rehabilitation Services

Dear Doctor
We have been informed that several of your psychologists might be
interested in performing consultative examinations for our Bureau.
To be included on our Panel of Consultants. ve must receive and review
each prospective panelist's curriculum vitae. These curricula vitae
should include the following:

1.
2.

3.
4.
5.
6.

7.
8.
*

School and date of graduation.
Place and data of graduate training and m y specialty
training.
Social Security Number.
RegistrationNumber.
Hoepita1 affiliationa.
Department name md addreme of any State of Illinois
personnel payroll(s] you &re on at this time. +
Individual Tax Identification Number (Pleame complete
attached Tax ldentificrtion 13rrmber Form.)
Corporate or group Tax Identification Number if one
is used for a group practice.

Eneloeed with this letter is information regarding the Disclosure of
Medical Information under the Federal Privacy Act of 1974. Our Bureau
is currently required to obtain a vritten acknowledgement of the
renponaibility of confidentiality from a11 permons who perform
consultative examinations. Therefore, please repueet each of your
psychologists to read the information carefully and for each to sign
one of the Medical Discloeure Acknowledgement forma m d the Licenee/
Credentials Certification statement enclosed.

*The 1lli.noie Purchasing Act prohibits State mployeee from receiving
money for goods or mervices in a contract satisfled by payment of funds
appropriated by the Illinole General Aeeembly. University euiployaee are
excepted.

A copy of the current fee schedule has been encloaed for informationel
purposes and future u8e.
Please forward to ua the curricula vitae m d the signed Medical
Dieclosure Acknowledgement forms. These applications will then be
given every consideration by the Credential8 Committee.
Sinemrely,

Edvard G. Ference, M.D.
Chief Medical Coneultnnt

Encloeurerr:

Federal Privacy Act Informational Sheet
Medical Diacloeure Acknowledgement/
License/Credentinla Certification
Tax Identification Number Form
Fqe Schedule
Envelope

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. The OMB control number for this
collection is 0960-0555. We estimate that it will take between 5 to 30 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to
our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

PRIVACY ACT STATEMENT
Collection and Use of Information by the Social Security Administration
The Privacy Act of 1974 (5 U.S.C. § 552a) requires us to provide certain facts to each person from whom we
request and collect information in order to administer our programs. These facts include:
• the statutory authority for the request;
• why we need the information;
• whether it is voluntary or mandatory for you to give us the information and the effects, if any, of not
giving us the information; and
• the uses we may make of the information you give us.
The following sections explain our collection, use, and disclosure of the information you give us. If you have
any questions about your rights and responsibilities under the Privacy Act, you may contact any local Social
Security office.
Our authority to collect information
Our specific authority to collect information is found
in sections 205(a), 702, 1631(e)(1)(A) and (B),
1631(f), 1872, and 1875 of the Social Security Act
(the Act), as amended. Additional authority is in
part B of the Federal Coal Mine Health and Safety
Act of 1969.

information to another agency or person without
your written consent. We make these disclosures
for the following reasons:
•
•
•

Why we need the information
We collect information from you in order to
administer our programs. Specifically, the
information we request enables us to:
•
•
•
•
•

assign Social Security numbers;
establish and maintain earnings records;
determine entitlement of applicants and
their families to insurance coverage and or
benefit payments;
issue payments in the right amount for the
right months to people entitled to them; and
conduct program-oriented research in areas
of income distribution and maintenance.

Is providing information voluntary or
mandatory?
It is not mandatory for you to give us the
information we request except in certain instances
explained below. It is usually to your advantage to
comply with our request for information. Failure to
do so, however, could prevent an accurate and
timely decision on a claim you file or result in the
loss of some benefit or service.
Our use(s) of the information you give us
We use the information you give us to administer
our programs. Sometimes we must disclose the

•

to enable a third party or agency to assist us
in establishing your right to benefits or
coverage;
to comply with Federal laws;
to make eligibility determinations in similar
Federal, State, and local health and income
maintenance programs;
to facilitate statistical research, audit, or
investigative activities necessary to assure
the integrity of our programs.

We may also use the information you give us when
we match records by computer. Computer
matching programs compare our records with those
of other Federal, State, or local government
agencies. We use the information from these
matching programs to establish or verify a person’s
eligibility for Federally-funded or administered
benefit programs and for repayment of payments or
delinquent debts under these programs.
A complete list of routine uses of the information
you give us is available in our Privacy Act Systems
of Records Notices. For example, the application
for benefits and supporting documentation of the
factors of entitlement and continuing eligibility is
contained in our Claims Folder System (60-0089);
medical information, doctors’ reports, and State
disability determinations related to a disability claim
is contained in our National Disability Determination
Services File System (60-0044). Additional
information regarding this form, routine uses of
information, and other Social Security programs is
available from our Internet website at
www.socialsecurity.gov or at your local Social
Security office.
Form SSA-5000 (05-2011)