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

Telehealth Acknowledgement Call Script



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 .



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?

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 preaddressed 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

See Revised Privacy Act &
PRA Statements attached
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.

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d), 1614(a) and 1631(d) 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 making preparation for, or
evaluating the results of, consultative medical examination or vocational assessments
which they were engaged to perform by SSA or a State agency acting in accord with
sections 221 or 1633 of the Act; and

•

To contractors, and other Federal agencies, as necessary, for the purpose of assisting
the Social Security Administration (SSA) in the efficient administration of its
programs. We will disclose information under this routine use only in situations in
which SSA may enter 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 Notices
(SORNs) 60-0044, National Disability Determination Services (NDDS) File, as published in the
Federal Register (FR) on January 11, 2006, at 71 FR 1810; 60-0089, Claims Folders Systems, as
published in the FR on October 31, 2019, at 84 FR 58422; and 60-0320, Electronic Disability
(eDIB) Claim File, as published in the 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.

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
(OMB) 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 regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.