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

TELEHEALTH CONSULTATIVE EXAMINATION AGREEMENT CALL SCRIPT – CHILD
< Parent or Legal Guardian Name>

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I am contacting you because we need more medical information for [name of claimant]’s
disability claim with the Social Security Administration (SSA). We are asking [name of
claimant] to attend a consultative examination so that
we can obtain that information. [Name of claimant] has the option to attend a telehealth
consultative examination, and I would like to discuss that option with you.
If the claimant is age 12 or older, ask that the claimant participate in the call as well.

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A telehealth consultative examination is conducted over the internet using video
technology that allows [name of claimant] 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 parent or legal guardian 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, [name of claimant] has the option to attend a telehealth
consultative examination. A telehealth consultative examination allows [name of
claimant] to attend the appointment from their home or other private location.
Would you be willing to consider a telehealth rather than an in-person examination?
If the parent or legal guardian is not willing to consider a THCE, stop.
Schedule an in-person CE.

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To attend a telehealth consultative examination, [name of claimant] will need to have
three things:
o
o
o

A private, indoor, quiet location where they can attend the examination;
A reliable internet connection they can use for the examination; and
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

TELEHEALTH CONSULTATIVE EXAMINATION AGREEMENT CALL SCRIPT – CHILD
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▪ A desktop computer.
Does [name of claimant] 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 [name of claimant] to attend a telehealth consultative examination, we
will schedule an examination in person.
If the parent or legal guardian is not able to provide the needed location and IT
or an adult claimant does not have the required ID, stop.
Schedule an in-person CE.

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Before you decide whether you agree to have [name of claimant] attend a telehealth
consultative examination, we want to make sure you know that the information
technology used for [name of claimant]’s 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 have [name of claimant] 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 have [name of claimant] attend a telehealth consultative
examination at any time before the examination.
If the parent or legal guardian wishes to opt out, stop.
Schedule an in-person CE.

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When attending a telehealth consultive examination, [name of claimant] must present a
valid, unexpired government-issued photo identification (ID) over the video connection.
[Name of claimant] may present ID documents, such as a United States (U.S.) Stateissued driver’s license, U.S. State-issued ID card, U.S. passport, U.S. military ID, or U.S.
tribal ID. If [name of claimant] does not have a valid, government-issued photo ID, you
may present an original government-issued non-photo ID document, such as a birth
certificate, or a nongovernment-issued photo ID, such as a student ID.
Do you understand the requirements for attending a telehealth consultative
examination?
Do you agree to have [name of claimant] attend a telehealth consultative examination?
If the parent or legal guardian does not agree, stop.
Schedule an in-person CE.
If the parent or legal guardian agrees and the claimant is age 12 or older, ask
the claimant whether they also agree to attend a telehealth CE.

TELEHEALTH CONSULTATIVE EXAMINATION AGREEMENT CALL SCRIPT – CHILD
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If at any time before the examination you change your mind about having [name of
claimant] attend a telehealth consultative examination, please call so
that we can schedule an in-person 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?