ERE transmission of MER forms (subset of "MER Samples" category)

Sample MER Forms

HER REQUEST FOR BosPITAL (ADULT)
DDS Letterhead
(includes mailing .address)

DATE:

RE:

Hospital address Line 1
Address Line 2
City, =ate ZIP

Claimant'r Name
Address Line 1
Address Line 2
City, State ZIP

-i

Patient ID:
SSN: 000-00-DO00
DOB: WH/DD/YY

A claim for Social Security disability benefits has been filed
for [CLAIMANT'S NAME] and we have been asked t o get medical
evidence for the claim.
Please provide [inpatient or outpatient] medical records for
[DATE:] t o [DATE or present].
Hedical records should include medical history, clinical and
laboratory findings, treatment prescribed and response,
diagnosis, prognosis, discharge summary, and a statement based on
medical findings, describing the patient's capacity t o perform
work-related activities.
o

Physical work activities include sitting, standing,
walking, lifting, carrying, handling objects, hearing,
speaking and traveling.

r Mental work activities include understanding and memory;

sustained concentration and persistence; social
interaction; and adaptation.
Please send either a narrative report or copies of your records
and sign your report.
THIS 16 NOT

)JJ

AUTHORIZATION FOR AN PXkMIHATION.

[include State information, if needed]

'1f you have any q u e s t i o n s about our r e q u e s t , p l e a s e c a l l [PHONE

NUMBER].
Thank you f o r your h e l p .

(OPTIONAL:
requester)
Enclosures:
Medical. R e l e a s e Form
.J

Name and t i t l e .dI
.

DDS Letterhead
(includes mailing address)
DATE:

:

C l i n i c / P h y s i c i a n T s Name and T i t l e
Address L i n e 1
Addgess L i n e 2
C i t y , State ZIP

C l a i m a n t 'I Name
Address Line 1
Address Line 2
c i t y , S t a t e ZIP

Patient ID:
SSN: 000-00-0000
DOB: IM/DD/YY
A claim f o r s o c i a l S e c u r i t y d i s a b i l i t y b e n e f i t s h a s b e e n f i l e d
f o r [CLAIMANT'S NAME] and w e h a v e b e e n a s k e d t o g e t m e d i c a l
evidence f o r t h e claim.
P l e a s e p r o v i d e m e d i c a l r e c o r d s from [DATE] t o [DATE or PRESENT].
Medical r e c o r d s should i n c l u d e medical h i s t o r y , c l i n i c a l and
l a b o r a t o r y f i n d i n g s , t r e a t m e n t p r e s c r i b e d and r e s p o n s e ,
d i a g n o s i s , p r o g n o s i s , and a s t a t e m e n t based on m e d i c a l f i n d i n g s ,
d e s c r i b i n g t h e p a t i e n t ' s c a p a c i t y t o perform work-related

activities.
0

P h y s i c a l work a c t i v i t i e s i n c l u d e s i t t i n g , s t a n d i n g ,
walking; l i f t i n g , carrying, handling objects, hearing,
s p e a k i n g and t r a v e l i n g .

0

M e n t a l work a c t i v i t i e s i n c l u d e u n d e r s t a n d i n g a n d memory;
s u s t a i n e d c o n c e n t r a t i o n and p e r s i s t e n c e ; s o c i a l
i n t e r a c t i o n ; and a d a p t a t i o n .

P l e a s e s e n d e i t h e r a n a r r a t i v e r e p o r t o r c o p i e s of y o u r r e c o r d s
and s i g n y o u r r e p o r t .
*

25916 I6 NOT Xh' AUTHORIZATION FOR AN LXRnINATIOH.

[ i n c l u d e S t a t e information, i f needed]
I f you h a v e a n y q u e s t i o n s a b o u t o u r r e q u e s t ,
[TELEPHONE NUMBER ] .

call

Thank you f o r y o u r h e l p .
(OPTIONAL:
requester)
Enclosures :
M e d i c a l R e l e a s e Form

Name a n d t i t l e

Of

.

MER REQUEST FOR HOSPITAL (CHILD)

DDS Letterhead

(includes mailing address)
DATE:
Hospital
Address Line 1
Address Line 2
City, St&e
ZIP

RE:

Claimant's Name
Address Line.1
Address Line 2
City, State ZIP

AKA:

Patient ID:
SSN: 000-00-0000
DDB: MN/DD/YY
A claim for Social Security disability benefits has been filed

for [CLAIMANT'S NAME] and we have been asked to get medical
evidence for the claim.
Please provide [inpatient or outpatient] medical records for the
dates; [DATE] to [DATE or present].
Medical records should include medical history, clinical and
laboratory findings, treatment prescribed and response,
diagnosis, prognosis, discharge summary, and a statement about
how the child's impairment(s1 and related symptoms affect his or
her daily activities and ability to perform age-appropriate
activities.
Domains of development or functioning that may be addressed are:
cognition; communication; motor abilities; social abilities;
respo-iveness to stimuli (in children from birth to the
attainment of age 1); personal/behavioral patterns (in children
from age 1 to the attainment of age 1 8 ) ; and concentration,
persistence, and pace in task completion (in children from age 3
to the attainment of age 18).
A narrative report, copies of your records, and completion of any

attached forms are equally satisfactory. Please sign your
repo:rt

.

TRIB XS NDT AN ADTBORIZATION FOR AH ZXAHINATION.

[include State information, if needed]

If you have any questions about our request, please call
[TELEPHONE NUMBER ] .

Thank you for your help.
(OPTIONAL:
requester)

Enclosures:
Medical Release
Form
.,

-

.d

Name find fftle of

HER REQUEST FOR C L I N I C / P R Y S I C I ~(CHILD1

DDS Letterhead
(includes mailing address)

DATE :

RE:

Clinic/Physician's Name and Title
A d w e s s Line 1
A d d G s s Line 2
City, State ZIP

Claimant's Name
Address Line 1
~ddresc~&lrie 2
City, *ate
ZIP

Patient ID:
SSN: 000-00-0000
DOE: NM/DD/YY

A claim for social Security disability benefits has been filed
for [ C L A I W T ' S NAME] and we have been asked t o get medical
evidence from you for the claim.
Please provide medical records from [DATE] to [DATE or PRESENT].
Hedical records should include medical history, clinical
findings, treatment prescribed and response, diagnosis,
prognosis, and a statement about how the child's impairment(s)
and related symptoms affect his or her daily activities and
ability t o perform age-appropriate activities.
Domains of development or functioning that may be addressed are:
cognition; communication; rotor abilities; social abilities;
responsiveness t o stimuli (in children from birth t o the
attainment of age 1); personalfbehavioral patterns (in children
from age 1 t o the attainment of age l a ) ; and concentration,
persistence, and pace in task completion (in children from age 3
t o the attainment of age 18).
A narrative report, copies of your records, and completion of any
attached forms are equally satisfactory. Please sign your
report.
THIS 16 NOT M AUTAORIZATION FOR M EXAHINATION.
[include State information, if needed]
I f you have any questions about our request, please call
[TELEPHONE NUMBER].
Thank you for your help.
(OPTIONAL:
requester)
Enclosures:
Medical Release Form

Name mnd title of

HER REQUEST FOR BCBDDL/INSTITUTION (CHILD)
DD6 tattarhaad
(includes mailing address)
DATE:
School/Institution
Address-~ine1
Address Line 2
City, Sta,te ZIP

RE:

'

'

claimanter Name
Address Line 1
Address Line 2
City, State ZIP

SSN: 000-00-0000
DOB: )IM/DD/YY
A claim for Social Security disability benefits has been filed
for [CLAIMANT'S NAHE] and we have been asked t o get evidence for
the claim.
Please send either a narrative report or copies of your records
and sign your report.
Records rhould include attendancefgrade reports, reports of any
referrals for or results of multi-disciplinary team evaluations,
anecdotdl records, medical records, and information about how the
child's impaiment(s) and related symptoms affect his or her
school activities and ability to perfonn age-appropriate
activities.
[include State information, if needed]

If y0.u have any questions about our request, please call [PHONE
NUMBERh
Thank you for your help.
(OPTIONAL:
requester)
Enclosures:
Authorization Release Form

Name and title of

W E R REQUEST FOR SlGHATURE ON TELEPBOHE R f P O R T (HER)

DDS Letterhead
(includes mailing address)
DATE :

~linic/~h~sician
Name
s~s
Addicss L i n e 1
Address L i n e 2
c i t y , s ~ a , t e ZIP

RE:

C l a i m a n t ' s Name
Address Line 1
Address Line 2
C i t y , S t a t e ZIP

Am:

SSN:
DOB :
Enclosed is a summary of t h e i n f o r m a t i o n you r e c e n t l y gave u s on
t h e t e l e p h o n e about t h i s claim f o r S o c i a l S e c u r i t y d i s a b i l i t y
benefits.
S o c i a l S e c u r i t y r e g u l a t i o n s r e q u i r e u s t o g e t your s i g n a t u r e on
t h i s medical report.
P l e a s e r e v i e w , s i g n , d a t e , and r e t u r n t h e e n c l o s e d r e p o r t t o u s .
P l e a s e make any r e v i s i o n s n e c e s s a r y . Your prompt r e s p o n s e w i l l
h e l p a s s u r e a t i m e l y d e c i s i o n on y o u r p a t i e n t ' s claim.
Thank you f o r your h e l p and c o o p e r a t i o n .

(OPTIONAL:

requestor)
Enclosure:
Medical R e p o r t

Name and t i t l e of