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

                                                             AGENCY

                                                            LETTERHEAD

 

                                                                                                                 Date: _______________

                                                                                                                  Case ID: [Fill-in]    

Addressee Name 

Address Line 1

Address Line 2

City, State, ZIP Code

 

PERMISSION TO PARTICIPATE IN A VIDEO CONSULTATIVE EXAMINATION

IMPORTANT: Please sign, date, and mail this form as soon as possible using the pre-addressed envelope provided.

Dear [First Name] [Last name],

In order to evaluate your disability claim fully, we need you to attend a consultative examination with a psychiatrist or psychologist.

Sometimes, it is possible to attend a consultative examination with a psychiatrist or psychologist, who is in a different location than you, using video technology. Under normal conditions, we use video technologies that meet certain privacy and security requirements. We typically hold these appointments in local Social Security field offices or at other secure public locations, such as the Disability Determination Services, that use secure broadband connections to maintain claimant privacy. However, these locations are not currently available.

To continue to serve the public during the COVID-19 nationwide public health emergency, we are permitting psychiatrists and psychologists to perform certain consultative examinations through additional remote video communications technologies. Some of these technologies, and the manner in which they are used, may not be secure. This may allow unauthorized third parties to access your personal information, including information about your personal health or identity collected during the examination. If you agree to participate in a consultative examination through video technology, we require you to present a government-issued photo identification (ID) over the video connection to confirm your identity, e.g., United States (U.S.) State-issued driver’s license, U.S. State-issued ID card, U.S. passport, U.S. military ID, or student or school ID.

We are contacting you to find out whether you will agree to attend a consultative examination using video technology that may be not be secure. Importantly, we do not require you to do so if you have concerns about the security of your personal information. If you choose not to pursue this option, we will continue to process your claim as we normally would, but there may be a delay until a psychiatrist or psychologist can perform a consultative examination in person or using more secure video technology, or until we receive adequate evidence to make a determination.

If you agree to participate, your state Disability Determination Services (DDS) will notify you which video technology the psychiatrist or psychologist will use prior to your exam. To participate in the video examination, the video technology platform that the examiner is using may ask or require you to agree to its third-party terms and privacy policies, which the DDS and SSA do not control. If you become concerned about using that video technology, you may ask us to postpone the examination at any time by calling the telephone number listed below. Asking us to postpone the examination will delay your determination, but it will not negatively affect the determination we make on your claim for benefits.

Please answer the below questions about how you would like to proceed with your consultative exam:

1. While we cannot guarantee complete privacy for these exams, are you willing to participate in a consultative examination voluntarily using a video technology that may not be secure?

• Yes

• No

2. Do you understand that you may change your mind at any time about attending a consultative examination using video technology that may not be secure, and that doing so will delay, but will not negatively affect the determination we make on your claim for benefits?

• Yes

• No

3. Do you acknowledge and accept that there is privacy risk to your personal information if you attend a consultative exam using video technology that may not be secure?

• Yes

• No

If you agreed above to participate in a video consultative examination, the DDS will inform you which video technology the psychiatrist or psychologist will use for your examination and will include instructions for using the technology.

As noted above, if you become concerned about using the video technology that the Disability Determination Service chooses for your examination, you may ask to postpone the examination by calling the Disability Determination Services at the telephone number listed below.  Asking to postpone the examination will delay, but will not negatively affect the determination we make on your claim for benefits. If you ask to postpone the examination, we will hold your claim until we can reschedule the examination in-person or using technology you agree to, or until we receive adequate evidence to make a determination.

__________________                       ______________________

(Your Signature)                                            (Date)     

__________________

(Printed Name)   

If you have any questions about this letter or need to contact us, call Monday through Friday between 8:00 a.m. and 4:00 p.m. at the phone number below.

 

Thank you,

 

(DDS Signature Information)__________________ 

DDS PHONE NUMBER Fill-in

DDS TTY/TRS Fill-in

Privacy Act Statement
Collection and Use of Personal Information

Sections 221(a), (i), and (j), and 1633(a) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may delay, but will not negatively affect the determination we make on your claim for benefits.

We will use the information you provide to acknowledge your willingness to participate in a video consultative examination. We may also share the information for the following purposes, called routine uses:

• To private medical and vocational consultants, for use in preparing for, or evaluating the results of, consultative medical examinations or vocational assessments which they were engaged to perform by SSA or a State agency, in accordance with sections 221 or 1633 of the Social Security Act; and

• To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of its programs. We disclose information under this routine use only in situations in which we may enter into a contractual or similar agreement with a third party to assist in accomplishing an agency function relating to this system of records.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0320, entitled Electronic Disability Claim File, as published in the Federal Register (FR) on June 4, 2020, at 85 FR 34477. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.