Statement From Excluded Medical Sources of Evidence

Section 812 of the Bipartisan Budget Act of 2015 (BBA 812) amends section 223(d)(5) of the Social Security Act (Act) by adding a subsection “C.” BBA 812 mandates that the Social Security Administration (SSA) implement the provisions of amended section 223(d)(5)(C)(i) by regulation by November 2, 2016. Section 223(d)(5)(C)(i) of the Act, as amended, requires SSA to exclude evidence (except for good cause) from medical sources: (1) convicted of a felony under sections 208 or 1632 of the Act; (2) excluded from participating in any Federal health care program under section 1128 of the Act; or (3) imposed with a civil monetary penalty (CMP), assessment, or both, for submitting false evidence, under section 1129 of the Act. These final, new regulations will require excluded medical sources to self-report their excluded status in writing each time they submit evidence related to a claim for benefits under Titles II or XVI of the Act. Excluded medical sources’ duty to self-report their excluded status will apply to evidence they submitted to SSA directly or through a representative, claimant, or other individual or entity. The self-report will include: (1) the heading "WRITTEN STATEMENT REGARDING SECTION 233(d)(5)(C) OF THE SOCIAL SECURITY ACT - DO NOT REMOVE[,]" (2) the name and title of the affected source; and (3) the applicable excluding event (i.e., felony conviction, section 1128 exclusion, or CMP or assessment under section 1129). Felons must also include their date of conviction, and those imposed with a CMP must provide the dates of imposition. Sources excluded under section 1128 must include: (1) the basis of their exclusion; (2) its effective date and anticipated length, and (3) whether the Department of Health and Human Services' Office of Inspector General waived it. The respondents for this collection are medical sources that (1) meet one of the exclusionary categories set forth in section 223(d)(5)(C)(i) of the Act, as amended, and (2) furnish evidence related to a claim for benefits under Titles II or XVI of the Act.

The latest form for Statement From Excluded Medical Sources of Evidence expires 2023-09-30 and can be found here.