MER Cover Letter--Child Medical Report

{@DMACOVER}

{@BARCDRIGHT}

{@SERIAL}

SOCIAL SECURITY ADMINISTRATION                                                  _

	Office of Medical & Vocational Expertise - OMVE Post Office Box 32908 Baltimore MD 21241-2908
	DATE: {@DATE}
{@VMADDR}	RE: {@CLMTADDR}
	SSN: {CSSN} {@PATIENTID} DOB: {CDOB}
	{@ALIAS}

{CFNAME} {CLNAME} has filed for disability benefits under the Social Security Act and has asked us to obtain medical evidence to document the claim.

{@alleg}

{@QUESTIONS}

Medical records should include medical history, clinical findings, treatment prescribed and response, diagnosis, prognosis, and a statement based on medical findings, describing the patient's functional limitations in learning, motor functioning, performing self-care activities, communicating, socializing, and completing tasks (and, if the child is a newborn or young infant from birth to age 1, responsiveness to stimuli). A narrative report, copies of your records, and completion of any attached forms are equally satisfactory. Please sign and date your report.

TO ENSURE PROMPT SERVICE, PLEASE RETURN THE COVER SHEET AND THIS LETTER WITH YOUR RESPONSE. IF YOU ARE REQUESTING PAYMENT FOR RECORDS, PLEASE SUBMIT YOUR PAYMENT REQUEST NO LATER THAN 90 DAYS FROM WHEN YOU SEND THE RECORDS.

{PFIRSTNAME} {PLASTNAME}
Case Manager
1-{PALTAREACOD}-{PALTEXCHG}-{PALTPHONE4}
Extension: {PALTEXT}
(toll free)

Enclosures: {@ENCLHV}

Authorization for Release of Medical Records
Business Reply Envelope

OMVE9006/{@OPER}{VMISC10}