Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category)

TELEHEALTH CONSULTATIVE EXAMINATION AGREEMENT CALL SCRIPT - ADULT

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I am contacting you because we need more medical information for your disability claim
with the Social Security Administration (SSA). We are asking you to attend a consultative examination so that we can obtain that information.
You have the option to attend a telehealth consultative examination, and I would like to
discuss that option with you. A telehealth consultative examination is conducted over the
internet using video technology that allows you and the provider to see and talk with
each other.
The Social Security Act allows us to collect this information, which we will use to
schedule the consultative examination. Providing this information is voluntary, but not
providing such will result in scheduling an in-person examination. As law permits, we
may disclose this information per routine uses in System of Records Notice(s) (SORN)
60-0044 and 60-0320. We may also use it in computer matching programs to establish
or verify eligibility for Federal benefit programs and to recoup debts under these
programs. This Privacy Act statement and all SORNs are available at
www.ssa.gov/privacy.
If the claimant does not have internet access or requests a copy of the Privacy Act statement,
send the full Privacy Act statement by letter.

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As I mentioned before, you have the option to attend a telehealth consultative
examination. A telehealth consultative examination allows you to attend the appointment
from your home or other private location.
Would you be willing to consider a telehealth rather than an in-person examination?
If the claimant is not willing to consider a THCE, stop.
Schedule an in-person CE.

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To attend a telehealth consultative examination, you will need to have three things:
o A private, indoor, quiet location where you can attend the examination;
o A reliable internet connection you can use for the examination; and
o A device with a camera and microphone, such as:
▪ A smartphone (delete smartphone if a speech and language
examination),
▪ A tablet (with a diagonal screen display of at least 9.7 inches if a speech
and language examination),
▪ A laptop, or
▪ A desktop computer.
Do you have access to these three things?
You may also need to have an email address and access to email because you may
receive some of the appointment information by email.
If you do not want to attend a telehealth consultative examination, we will schedule an
examination in person.

TELEHEALTH CONSULTATIVE EXAMINATION AGREEMENT CALL SCRIPT - ADULT

If the claimant is not able to provide the needed location and IT, stop.
Schedule an in-person CE.

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Before you decide whether you agree to attend a telehealth consultative examination,
we want to make sure you know that the information technology used for your exam will
not be owned by SSA. Also, while the providers who perform consultative examinations
for us are required to use online services that meet certain privacy and security
requirements, there are privacy or security risks that may be associated with use of
online services.
If you agree to attend a telehealth consultative examination, we will tell you before the
examination which video technology will be used for the examination. We will also
provide instructions on how to access the technology. You may be asked to agree to
third-party terms and privacy policies of the video technology provider. Neither this office
nor SSA controls the terms of service or privacy policies of third-party video technology
providers.
You can decide not to attend a telehealth consultative examination at any time before
the examination.
If the claimant wishes to opt out, stop.
Schedule an in-person CE.

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When attending a telehealth consultive examination, you must present a valid,
unexpired, government-issued photo identification (ID) over the video connection. You
may present ID documents, such as a United States (U.S.) State-issued driver’s license,
U.S. State-issued ID card, U.S. passport, U.S. military ID, or U.S. tribal ID.
Do you have an unexpired, government-issued photo ID?
Do you understand the requirements for attending a telehealth consultative
examination?
Do you agree to attend a telehealth consultative examination?
If the claimant does not agree, stop.
Schedule an in-person CE.

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If at any time before the examination you change your mind about attending a telehealth
consultative examination, please call so that we can schedule an inperson examination. We will also include a telephone number in your appointment notice
that you can use to contact us.
What is the email address where you can receive information and instructions for the
examination?