Treating Physician Consultative Examination Interest Form (Currently Used)

EXHIBIT B Form Approved

Social Security Administration 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

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.

PAPERWORK 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.

2

Form SSA-84 (09-2007)