Telehealth Consultative Examination Agreement Call Script (current)

TELEHEALTH CONSULTATIVE EXAMINATION AGREEMENT CALL SCRIPT

EM-23XXX Information Security Instructions and Scheduling Requirements for
Telehealth Consultative Examinations
When contacting the claimant (parent of a minor child or legal guardian) by telephone, DDS or
OHO will:
• Verify the individual’s identity consistent with existing policy for disclosure
and identity (DI 39567.210 and GN 00203.020),
• Advise the individual that personal information will be collected during this
telephone call, and
• Confirm the individual is in a private location in which no one can overhear
the conversation.
After confirming the individual’s identity, read aloud the following script, which provides
required information for the claimant (parent of a minor child or legal guardian) to determine
their willingness to participate in a THCE, and solicits the agreement/consent needed to
proceed with scheduling the THCE. Pause as needed to respond to any questions the
individual may ask.
Agreement Call Script

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I am contacting you because we need more medical information for your (name of
claimant’s) disability claim with the Social Security Administration (SSA). We are
asking you (name of claimant) to attend a consultative examination so that we can obtain that information. You
(name of claimant) 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 (name of
claimant) and the provider to see and talk with each other.
Before we proceed, the Social Security Act allows us to collect the information you
provide, which we will use to schedule the consultative examination. Providing this
information is voluntary, but not providing such will result in scheduling you for an inperson examination instead of a telehealth examination. As law permits, we may
disclose your information per routine uses within System of Records Notice(s) 600044 and 60-0320, available at www.ssa.gov/privacy. 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. You may locate the full Privacy Act statement on
the Telehealth Consultative Examination Agreement Form at (add webpage).

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 (name of claimant) have the option to attend a telehealth
consultative examination. A telehealth consultative examination allows you (name of
claimant) to attend the appointment from your (their) 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.

TELEHEALTH CONSULTATIVE EXAMINATION AGREEMENT CALL SCRIPT
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(Read only if a government-provided location is available.) If you attend ([name of
claimant] attends) at a location of our choice, we will provide a private room and the
equipment.
If you attend ([name of claimant] attends) at a location of your choice, you may need
to have an email address and access to email because the appointment information
may be sent by email. You may also need to agree to third-party terms of use or
privacy policies of the online service.
If you attend ([name of claimant] attends) at a location of your choice, [you/name of
claimant] will need access to three things:
o A private, indoor, quiet location where you (they) can attend the examination.
o A reliable internet connection you (they) can use for the examination.
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 (Does [name of claimant] have access to these three things?
If you do not want to attend (do not want [name of claimant] to attend) a telehealth
consultative examination, we will schedule an examination in person.
If the claimant is not able to provide the needed location and IT and declines
to attend at a government-provided location (or one is not available), stop.
Schedule an in-person CE.

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Before you decide whether you agree to attend (have [name of claimant] attend) a
telehealth consultative examination, we want to make sure you know that the
information technology used for your exam at a location of our choice may not be
owned by SSA. If you attend at a location of your choice, we will require the provider
who performs the consultative examination for us to use online services that meet
certain privacy and security requirements, but privacy or security risks still may be
associated with use of those services.
If you agree to attend (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 (name of claimant) may be asked to agree to third-party terms and
privacy policies of the video technology provider. Neither the State Disability
Determination Services (DDS) nor SSA controls the terms of service or privacy
policies of third-party video technology providers.
You can decide not to attend (not to have [name of claimant] 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 (name of claimant) must
present a valid, government-issued photo identification (ID) over the video connection.
You (claimant name) could 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. For a child who does not have a valid, government-issued photo

TELEHEALTH CONSULTATIVE EXAMINATION AGREEMENT CALL SCRIPT

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ID, you could 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 attend (have [name of claimant] 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 (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?