Form SSA-3023 Medical Consultant's Review of Psychiatric Review Techni

Form Approved
OMB No. 0960-0677

SOCIAL SECURITY ADMINISTRATION

SSN:

-

-

NAME:

MEDICAL CONSULTANT'S REVIEW
OF PSYCHIATRIC
REVIEW TECHNIQUE FORM

NH's NAME (If DWB, CDB, or DC Claim):
PRTF COMPLETED BY (Identify DDS or RO):
DATE OF PRTF BEING REVIEWED:

TYPE OF CLAIM: LEVEL OF CLAIM:
Initial

CDR

Initial

Recon

DHU

This form is to be completed by the reviewing medical consultant (MC) ONLY when a signed PRTF is
in file and it is determined that a PRTF was appropriate.
Part I below serves to record agreement/disagreement with Sections I, III, and IV of the PRTF.
Part II serves for the reviewing MC to explain in DETAILED NARRATIVE FORMAT the evidentiary
bases for recording a disagreement in Part I.
Indicate agreement, disagreement, or not applicable by checkmark for EACH item below.
IMPORTANT - Indicate disagreement ONLY for SUBSTANTIVE issues.

I. SUMMARY OF AGREEMENT/DISAGREEMENT
AGREE

DISAGREE

NA

A. Categories of Disorders
(Section IIA-I of PRTF)
B. Rating of Functional Limitations
(Section IIIA 1-4 of PRTF)
1. Daily Activities
2. Social Functioning
3. Concentration, Persistence, or Pace
4. Decompensation
C. Listing 12.02C, 12.03C, or 12.04C in Remission
(Section IIIB1 of PRTF)
D. Listing 12.06C
(Section IIIB2 of PRTF)
E. Medical Disposition
(Section IB 1-8 of PRTF)

MEDICAL CONSULTANT'S SIGNATURE:
Form SSA-3023 (6-2006)

ef (6-2006)

MC CODE:

DATE:

II. NARRATIVE DISCUSSION
Complete this section ONLY for discusion of areas of SUBSTANTIVE DISAGREEMENT. Present a
complete and detailed NARRATIVE discussion of the basis for disagreement for EACH area.
Begin the NARRATIVE DISCUSSION with a statement of why the PRTF assessment is in question.
Include a statement of the specific evidence that supports your conclusions, which differ substantively
from those presented in the PRTF assessment. If the disagreement is due to missing or incomplete
evidence, identify the evidence that is needed.

Continued On Attached Page

CENTRAL OFFICE REVIEW
Central Office (CO) Reviewing Medical Consultant (MC)
assessment on this form.

AGREES

DISAGREES with the

In disagreements, the reviewing CO MC is to complete and attach
Form SSA-416, discussing the disagreement issues(s).
MC CODE
CO MC Signataure
Form SSA-3023 (6-2006)

Date
ef (6-2006)

See Revised Privacy Act Statement
Privacy Act Statement: Section 223 and section 1633 of the Social Security Act authorize the
information requested on this form. The information provided will be used in making a decision on this
claim. Completion of this form is mandatory in disability claims involving mental impairments. Failure
to complete this form may result in a delay in processing the claim. Information furnished on this form
may be disclosed by the Social Security Administration to another person or government agency only
with respect to Social Security programs and to comply with federal laws requiring the exchange of
information between Social Security and another agency.
We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government agencies.
Many agencies may use matching programs to find or prove that a person qualifies for benefits paid
by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information about you may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
office.
See Revised Paperwork Reduction Act Statement
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 control
number. We estimate that it will take about 12 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213. You may send comments on our
time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

Form SSA-3023 (6-2006)

ef (6-2006)

The following revised Privacy Act Statement Statement will be inserted
into the form at its next scheduled reprinting:

PRIVACY ACT NOTICE
Collection and Use of Personal Information
Sections 223 and 1633 of the Social Security Act, as amended, authorize us to collect the
information requested on this form. The information you provide will be used to make a
decision on this disability claim. Your response is voluntary. However, failure to
provide the requested information may prevent an accurate and timely decision on any
claim filed, or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for
determining entitlement to Social Security benefits. We may, however, disclose the
information provided on this form in accordance with approved routine uses of the
Privacy Act (5 U.S.C. § 552a(b)), which include but are not limited to the following:
1. To enable an agency or third party to assist Social Security in establishing rights
to Social Security benefits and/or coverage;
2. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level;
3. To comply with Federal laws requiring the disclosure of the information from our
records; and,
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of SSA programs.
We may also use the information you provide when we match records by computer.
Computer matching programs compare our records with those of other Federal, State, or
local government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and other Social
Security programs are available from our Internet website at www.socialsecurity.gov or
at your local Social Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 control number. We estimate that it will take about 12
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.