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 [name of claimant]’s
conditions. We are asking [name of claimant] to attend a [mental or speech and language]
consultative examination so that we can obtain that information.
[Name of claimant] has the option to attend a telehealth consultative examination. A telehealth
consultative examination is conducted over the internet using video technology that would allow
[name of claimant] and the provider to see and talk with each other. A telehealth consultative
examination would allow [name of claimant] to attend the appointment from [name of
claimant]’s home or other private location.
What You Need to Attend
If [name of claimant] attends a telehealth consultative examination, [name of claimant] 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: [name of claimant] 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, [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.) State-issued 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 government-issued photo ID, you may present an original governmentissued non-photo ID document, such as a birth certificate, or a nongovernment-issued photo ID,
such as a student ID.
What You Need to Know
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.

OMB No. 0960-0555

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 [name of claimant]’s
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.

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 [name of claimant] to attend a telehealth consultative examination, we will
schedule a consultative examination in person. You can decide not to have [name of claimant]
attend a telehealth examination at any time before the examination. If you agree to have [name of
claimant] 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, [name of
claimant]'s 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 have [name of claimant] 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 have [name of claimant] attend a telehealth consultative examination, does
[name of claimant] have the following:
A. Access to a private, indoor, quiet location where [name of claimant] can attend the
examination?
□ Yes
□ No
B. Access to a reliable internet connection [name of claimant] 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 [name of claimant] 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 [name of claimant] could use for the examination?)
□ Yes
□ No
3. Do you understand that you may change your mind about having [name of claimant] attend 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.
______________________________________
(Parent or Legal Guardian Signature)

_______________________
(Date)

______________________________________
(Printed Name)
If [name of claimant] is age 12 or older, they must also agree to attend the examination by
telehealth.
______________________________________
(Child’s Signature)
______________________________________
(Printed Name)

_______________________
(Date)

OMB No. 0960-0555

4. If you agree to have [name of claimant] 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.