Form SSA-84 Treating Physician Consultative Examination Interest For

EXHIBIT B
Social Security Administration

Form Approved
OMB No. 0960-0751

Claimant Name
SSN

TREATING PHYSICIAN CONSULTATIVE EXAMINATION INTEREST FORM
The Social Security Administration occasionally must purchase additional supporting medical documentation to
evaluate an individual’s eligibility for disability benefits.
If you are interested in examining this claimant, should additional medical evidence be necessary, our general
requirements are:
•

Appointments will be scheduled within 7-10 days from the date we call your office;

•

Typed reports, ancillary tests results and any necessary report forms will be returned to us within 7 days of the
exam;

•

You will accept our fees as payment in full for an examination or for any ancillary tests;

•

Only tests authorized by the Office of Medical and Vocational Expertise (OMVE) will be performed;

•

Treatment will not be paid for by the OMVE; and

•

Examinations or tests (if needed), would be scheduled after your initial report is received.

If you are willing to examine this claimant, check the block below and return this form along with your
patient’s medical records. If you do not complete and return this from, we will assume that you are not interested
in doing these exams.
THIS IS NOT AN AUTHORIZATION TO PERFORM AN EXAMINATION. SHOULD AN EXAMINATION
BE NEEDED, WE WILL CONTACT YOU.
YES, I am interested.
Physician’s Name
Address

Office Telephone
(

)

Tax ID Number
Medical Specialty

Form SSA-84 (09-2007)

1

EXHIBIT B
Social Security Administration

See Revised Privacy Act
Statement

Form Approved
OMB No. 0960-0751

PRIVACY ACT/PAPERWORK REDUCTION ACT NOTICE
The information requested on this form is authorized by the Social Security Act, Title 20 CFR
404.1519h and 401.1519i. This information is needed to ascertain whether you are interested in
performing a consultative examination for the Social Security Administration on the individual
identified on this form. The information you provide will be used to contact you if a consultative
examination is requested. Information requested on this form is voluntary. However, if you do not
provide the required information, we will be unable to contact you to schedule the consultative
examination. While the information you furnish on this form would almost never be used for any
purpose other than ascertaining your interest in conduction a consultative examination, such information
may be disclosed by SSA for the following purposes (1) to assist SSA in determining the right to Social
Security benefits for yourself or another person; (2) to facilitate statistical research and audit activities
necessary to assure the integrity and improvement of programs administered by SSA, and (3) to comply
with laws and regulations requiring the exchange of information between SSA and another agency.
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
PAPERWORK REDUCTION ACT Reduction Act
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 5 minutes
to read the instructions, gather the facts, and answer the questions. You may send comments on our time
estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Only comments relating to
our time estimate should be provided, not the completed form.

Form SSA-84 (09-2007)

2

SSA will insert the following revised Privacy Act Statement into the
form at its next scheduled reprinting:
Treating Physician Consultative Examination Interest, Form SSA-84
Privacy Act Statement
Collection and Use of Personal Information
Section 221(j) [42 U.S.C. 421(j)] of the Social Security Act and Title
20 C.F.R. §§ 404.1519h and 404.1519i authorizes us to collect this information. We
will use the information you provide to ascertain whether you are interested in
performing a consultative examination for the Social Security Administration on the
individual identified on this form. We will use the information you provide to contact
you if a consultative examination is requested. The information you provide on this
form is voluntary. However, if you do not provide the requested information, we will
be unable to contact you to schedule the consultative examination.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another
person or to another agency in accordance with approved routine uses, which include
but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office, General
Services Administration, National Archives Records Administration, and the
Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by 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.
A complete list of routine uses for this information is available in our System of
Records Notice entitled, Claims Folder System, 60-0089. This notice, additional
information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at any Social Security
office.

SSA will insert the following revised PRA Statement 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 5
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.