Category I - CE c) Report to Med Provider - Current

Samples

Model Response Form 2

Date: {Date}
Case ID: {Case ID}

Barcode
{Addressee Name}
{Address Line 1}
{Address Line 2}
{City, State, ZIP Code}
AUTHORIZATION TO RELEASE CONSULTATIVE EXAMINATION REPORT
Appointment Information
Evaluator Information
{CE Provider Name}
{CE Provider Address}

Date and Time
Type of Appointment
{Weekday}
{CE Procedure}
{Appointment Date}
{Appointment Time}

I, {Claimant Full Name}, authorize the Social Security Administration to send a copy of the
consultative examination report(s) for the appointment(s) listed above to:
Doctor Name: __________________________________________________________________
Address Line 1: ________________________________________________________________
Address Line 2: ________________________________________________________________
City, State, ZIP code: ___________________________________________________________
Phone: _________________________

Fax: __________________________

I understand this authorization is valid for 90 days from the date signed. I can revoke this
authorization sooner if I submit a written request to do so.
_________________________________________ __________________
Your Signature
Date
_________________________________
Current Address

________________
City

_________________________________
Current Phone Number
_______
State

____________
Zip

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d) and 1631(d) and (e) of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent us from making an accurate and timely
decision on any claim filed.
We will use the information to make a determination regarding your ability to perform workrelated activities. We may also share your information for the following purposes, called routine
uses:
1. To private medical and vocational consultants for use in making preparation for, or
evaluating the results of, consultative medical examination or vocational assessments
which they were engaged to perform by SSA or a State agency acting in accord with
sections 221 or 1633 of the Act; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We
will disclose information under this routine use only in situations in which SSA may enter
into a contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0044, entitled National Disability Determination Services File System and 60-0089,
entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are
available on our website at www.socialsecurity.gov/foia/bluebook.
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. We estimate that it will take about 20 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.