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

OMB No. 0960-0555

Agency Letterhead
Date: ______________
Case ID: ___________

Addressee Name
Address Line 1
Address Line 2
City, State, ZIP Code

We are the office that makes disability decisions for the Social Security Administration (SSA).
We are writing to you because we need more medical information about your condition(s). We
are asking you to attend a [mental or speech and language] consultative examination so that we
can obtain that information.
You have the option to attend a telehealth consultative examination. A telehealth consultative
examination is conducted over the internet using video technology that would allow you and the
provider to see and talk with each other. A telehealth consultative examination would allow you
to attend the appointment from your home or other private location.
What You Need to Attend
If you attend a telehealth consultative examination, you will need to use a smartphone, tablet,
laptop, or desktop computer that has a camera, microphone, and reliable internet connection.
(For a speech and language examination: you will need to use a laptop, desktop computer, or
tablet with diagonal screen display of at least 9.7 inches that has a camera, microphone, and
reliable internet connection.)
When attending a telehealth consultative 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.
What You Need to Know
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 your examination. We will also provide
instructions on how to access the technology. You may be asked to agree to third-party terms and

OMB No. 0960-0555

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.
What You Need to Do Next
Complete the enclosed form(s) to tell us how you would like to proceed with the consultative
exam by [current_date+10]. Please use black or blue ink and return the form.
How to Return The Form
You may use the enclosed return envelope or fax your completed form to us at . Please note the return address may be to a scanning center who works with us. The
completed form must include the barcode page on top of the form.
If You Decide to Attend In Person
If you do not want to attend a telehealth consultative examination, we will schedule a
consultative examination in person. You can decide not to attend a telehealth examination at any
time before the examination. If you agree to attend a telehealth consultative examination and
then you change your mind, please call us at the number(s) shown below Monday-Friday
between [local_office_open] and [local_office_close] 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.
If You Have Any Questions
If you have any questions about the examination or completing this form, please call us at the
number(s) shown below Monday-Friday between [local_office_open] and [local_office_close].
When you call or leave a message, please provide the Case ID: [case_id], your name, and a call
back number.

Thank you for your help,
[Standard Signature Block]

OMB No. 0960-0555

PLEASE COMPLETE AND RETURN
TELEHEALTH CONSULTATIVE EXAMINATION AGREEMENT FORM

1. Do you agree to attend a telehealth consultative examination voluntarily?
□ Yes
□ No (If you select “No,” we will schedule an in-person consultative examination)
2. If you agree to attend a telehealth consultative examination, do you have the following:
A. Access to a private, indoor, quiet location where you can attend the examination?
□ Yes
□ No
B. Access to a reliable internet connection you could use for the examination?
□ Yes
□ No
C. Access to a device with a camera and microphone, such as a smartphone, tablet, laptop,
or desktop computer that you could use for the examination? (For speech and language
examination: Access to a device with a camera and microphone, such as a tablet with a
diagonal screen display of at least 9.7 inches, laptop, or desktop computer that you could
use for the examination?)
□ Yes
□ No
D. Valid, unexpired government-issued photo ID that you could present at the examination?
□ Yes
□ No
3. Do you understand that you may change your mind about attending a telehealth consultative
examination at any time before the examination?
□ Yes
□ No
By signing below, I am indicating that I have read and understand this form.
______________________________________
(Claimant Signature)

_______________________
(Date)

______________________________________
(Printed Name)
4. If you agree to attend, you may receive some of the appointment information by email. Please
provide the email address where you wish to receive the appointment information:
____________________________
Email Address

OMB No. 0960-0555

Privacy Act Statement
Collection and Use of Personal Information
Sections 221 and 1633 of the Social Security Act, as amended, allow us to collect this
information, which we will use to schedule a consultative examination either in person or by
telehealth, depending on whether you agree to a telehealth examination. Providing this
information is voluntary; not providing all or part of the information may delay, but will not
negatively affect the determination we make on your claim for benefits. As law permits, we may
use and share the information you submit, including with private medical and vocational
consultants, other Federal agencies, contractors, and others, as outlined in the routine uses within
System of Records Notice(s) 60-0044 and 60-0320, available at www.ssa.gov/privacy. The
information you submit may also be used in computer matching programs to establish or verify
eligibility for Federal benefit programs and to recoup debts under these programs.

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 5 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.