Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category)

Disability Case Development Information Collections

Telehealth Acknowledgement Call Script

Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category)

OMB: 0960-0555

Document [docx]
Download: docx | pdf

Telehealth Acknowledgement Call Script


<Claimant Name>


  • In order to fully evaluate your disability claim, SSA needs to conduct a consultative examination with a psychiatrist or psychologist in your area.


  • Sometimes SSA offers these examinations via videoconferencing technologies with medical providers who are in a different location. Under normal conditions, the videoconferencing technologies used meet certain privacy and security requirements.


  • In order to continue to serve the public during the COVID-19 nationwide public health emergency, SSA is permitting certain providers to perform consultative exams through remote communications technologies.  Some of these technologies, and the manner in which they are used, may not be secure. This may allow your personal information to be accessed by unauthorized third parties.


  • Some of our consultative examination providers have agreed to conduct these examinations via such technologies that may not be secure including <list non-HIPAA compliant options (Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype) available for your providers>.  


  • While we cannot guarantee complete privacy for these exams, are you willing to participate in a consultative examination via one of these remote communications technologies?


  • If so, which remote communications technology are you able to use?


  • Do you acknowledge this privacy risk and agree to proceed with your consultative exam using ______ technology?


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorNaomi Sipple
File Modified0000-00-00
File Created2021-01-14

© 2024 OMB.report | Privacy Policy