Download:
pdf |
pdfSCREEN PACKAGE DOCUMENT
MEDICAL CONTINUING DISABILITY REVIEW APPLICATION
OR I454
Screen Package Document – Medical CDR Application
Table of Contents
1.
Screen Designs and Component Descriptions ............................................................................................. 3
1.1.
My Social Security Landing Page.................................................................................................................. 3
1.2.
Privacy Act Statement: Collection and Use of Personal Information .......................................................... 4
1.3.
Permission to Release Records (SSA-827) ................................................................................................... 5
1.4.
Save and Exit ................................................................................................................................................ 7
1.5.
Instructions .................................................................................................................................................. 8
1.5.
Information about You................................................................................................................................. 9
1.6.
Someone We Can Contact ......................................................................................................................... 13
1.7.
Medical Conditions .................................................................................................................................... 17
1.8.
Medical Providers ...................................................................................................................................... 19
1.9.
Tests ........................................................................................................................................................... 24
1.10.
Medicines ............................................................................................................................................... 29
1.11.
Assistive Devices..................................................................................................................................... 33
1.12.
Other Medical Information .................................................................................................................... 37
1.13.
Work ....................................................................................................................................................... 40
1.14.
Support Services ..................................................................................................................................... 41
1.15.
Training................................................................................................................................................... 47
1.16.
Education................................................................................................................................................ 50
1.17.
Daily Activities ........................................................................................................................................ 53
1.18.
Remarks .................................................................................................................................................. 55
1.19.
Summary................................................................................................................................................. 55
1.20.
Receipt.................................................................................................................................................... 61
OPPM/DUEA/UXG
2
Screen Package Document – Medical CDR Application
1. Screen Designs and Component Descriptions
1.1.
My Social Security Landing Page
A user can access the Continuing Disability Review application or i454 from their my Social Security homepage.
OPPM/DUEA/UXG
3
Screen Package Document – Medical CDR Application
1.2.
Privacy Act Statement: Collection and Use of Personal Information
A user is provided with the Privacy Act Statement before prior to completion of the i454.
OPPM/DUEA/UXG
4
Screen Package Document – Medical CDR Application
1.3.
Permission to Release Records (SSA-827)
The user has an option to sign SSA-827 electronically and continue completing the i454 or complete both
forms on paper and mail them to SSA.
NOTE: Upon accessing the Continuing Disability Review application, a footer as shown below will display.
OPPM/DUEA/UXG
5
Screen Package Document – Medical CDR Application
The “OMB No.0960-0072” is linked to the Paperwork Reduction Act. The user has the option to print the
Paperwork Reduction Act and the Privacy Act Statement. The footer is persistent throughout the application
and will not be shown on the upcoming pages.
If the user selects “I agree to electronically sign the release form,” an informational message appears below,
letting the user know that they can print and/or save their electronically signed release form upon submission.
If the user selects “I decline to electronically sign the release form.” a warning message appears below, letting
the user know how to submit their review and the release form using paper forms. Links to the SSA-454 and
SSA-827 forms are included.
OPPM/DUEA/UXG
6
Screen Package Document – Medical CDR Application
1.4.
Save and Exit
If the user decides to exit the application at any point, they can select the “Save and Exit” button.
The following confirmation message will display.
OPPM/DUEA/UXG
7
Screen Package Document – Medical CDR Application
1.5.
Instructions
The user can review what documents they need to have available for completing the i454.
The side navigation on right displays on all screens within the application. Users can either go through the
screens of the application in order or access any of the screens from the right navigation if they prefer. Green
check marks indicate sections completed without errors.
The right navigation is persistent throughout the application and will not be shown in the upcoming
screenshots.
OPPM/DUEA/UXG
8
Screen Package Document – Medical CDR Application
1.5.
Information about You
The user needs to respond to several questions about using other names as well as their ability to
communicate. Since the user is authenticated to their my Social Security portal, their name, address, email,
and phone do not need to be entered.
OPPM/DUEA/UXG
9
Screen Package Document – Medical CDR Application
If the user selects “Yes” to the question about using other names on medical or educational records, the Name
fields will display. The user can add more than one name, if needed.
OPPM/DUEA/UXG
10
Screen Package Document – Medical CDR Application
If the user selects “No” to the question “Can you speak and understand English?” they can select a language of
their preference from the dropdown list.
The list of languages is coming from the Global Reference Table (GRT).
OPPM/DUEA/UXG
11
Screen Package Document – Medical CDR Application
If the user cannot locate the language of their preference, they can select “Other” and specify in the field
provided.
If the user selects any language under the “What written language do you use every day in most situations (at
home, work, school, in community, etc.)?” question, two additional questions about reading and writing will
be displayed.
OPPM/DUEA/UXG
12
Screen Package Document – Medical CDR Application
If the user cannot locate the language of their preference, they can select “Other” and specify in the field
provided.
1.6.
Someone We Can Contact
The user is asked to provide a contact person.
OPPM/DUEA/UXG
13
Screen Package Document – Medical CDR Application
If the user answers “Yes” to the “Is there someone we can contact who can help with your case?” question,
additional fields will appear below to capture details.
OPPM/DUEA/UXG
14
Screen Package Document – Medical CDR Application
The user can select their relationship with the contact person from a list as shown below.
If the user selects “Other” from the list, they can specify their relationship in the field provided.
If the user answers “No” to their contact’s ability to speak and understand English, they can select a language
other than English from the list. The list of languages is coming from the GRT table.
OPPM/DUEA/UXG
15
Screen Package Document – Medical CDR Application
If the user selects “Other,” they can specify what language their contact prefers.
OPPM/DUEA/UXG
16
Screen Package Document – Medical CDR Application
1.7.
Medical Conditions
The user can list their medical conditions as well as their height and weight.
OPPM/DUEA/UXG
17
Screen Package Document – Medical CDR Application
The user can switch to the metric system when entering height and weight, if needed.
OPPM/DUEA/UXG
18
Screen Package Document – Medical CDR Application
1.8.
Medical Providers
The system propagates medical providers from the user’s last review or initial application. The user must
review and update medical providers they have seen in the last 12 months or have an upcoming appointment
with.
To update medical provider information, the user can select the “Review” button, which will take them to the
Medical Provider Details page with certain data propagated from the last review.
OPPM/DUEA/UXG
19
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
20
Screen Package Document – Medical CDR Application
Upon saving, the user will be taken back to the Medical Providers page. The “NEEDS REVIEW” warning status
badge will be replaced by the “REVIEWED” success badge.
If the user needs to delete a provider, they can click the “Delete” button. Upon clicking on “Delete,” the
following confirmation message will display.
OPPM/DUEA/UXG
21
Screen Package Document – Medical CDR Application
If the user needs to add a provider, they can select the “Add Medical Provider” button.
OPPM/DUEA/UXG
22
Screen Package Document – Medical CDR Application
Upon saving, the user will be taken back to the Medical Providers page. The informational status badge “NEW”
will be displayed against the provider added.
If no medical providers were reported in the last review, the user will see a corresponding instructional
message and a blank Medical Providers table.
OPPM/DUEA/UXG
23
Screen Package Document – Medical CDR Application
1.9.
Tests
The user can enter details of tests ordered by their providers in the last 12 months.
When the user selects “Yes,” a blank Tests table will appear.
OPPM/DUEA/UXG
24
Screen Package Document – Medical CDR Application
If the user selected the “Add Test” button, it will bring up the Test Details page where the user can enter test
information.
The user can select a test from the list “Test Type.”
OPPM/DUEA/UXG
25
Screen Package Document – Medical CDR Application
If either Biopsy, MRI/CT Scan, or X-ray is selected from the Test Type dropdown list, the user has to provide
the body part:
If a test is not on the list, the user can select “Other” and specify.
Then, the user can select a provider who ordered the test under “Ordered by.” The list will contain medical
providers already entered as well as other options. If the provider is not on the list, the user can select “Other
Medical Provider” and enter details as seen under the Medical Providers.
Note: the same interaction will take place when users are entering Medicines.
OPPM/DUEA/UXG
26
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
27
Screen Package Document – Medical CDR Application
Upon saving test details, the user will be taken back to the Tests page where the table is populated with a new
entry designated by the “NEW” information status badge.
OPPM/DUEA/UXG
28
Screen Package Document – Medical CDR Application
1.10.
Medicines
The system propagates medicines from the user’s last review or initial application. The user must review and
update medicines, based on the last 12 months.
The user can update a medicine by selecting the “Review” button. The “Review” button brings up a page titled
“Medicine Details” with data propagated from the last review. The user can review and update details, as
needed. The “Prescribed by” dropdown includes providers already entered as well as the “Other Medical
Provider” option.
OPPM/DUEA/UXG
29
Screen Package Document – Medical CDR Application
Upon saving, the user will be taken back to the Medicines page. The “NEEDS REVIEW” warning status badge
will be replaced by the “REVIEWED” success badge.
OPPM/DUEA/UXG
30
Screen Package Document – Medical CDR Application
If the “Add Medicine” button is selected, the Medicine Details page will display.
Upon saving medicine details, the user will return to Medicines page where the table is populated with a new
entry designated by the “NEW” information status badge.
OPPM/DUEA/UXG
31
Screen Package Document – Medical CDR Application
If no medicines were reported in the last review, the user will see a corresponding informational message and
a blank Medicines table.
OPPM/DUEA/UXG
32
Screen Package Document – Medical CDR Application
1.11.
Assistive Devices
The user can add assistive devices they are using.
If the user selects “Yes,” a blank Assistive Devices table will appear below.
OPPM/DUEA/UXG
33
Screen Package Document – Medical CDR Application
If the “Add Assistive Device” button is selected, then the Assistive Device Details page will display.
OPPM/DUEA/UXG
34
Screen Package Document – Medical CDR Application
The user can select an assistive device from the list. If the assistive device is not listed, the user can select
“Other” and specify.
Then, the user can select a provider who prescribed the device under “Prescribed by.” The list will contain
medical providers already entered as well as other options. If the provider is not on the list, the user can select
“Other Medical Provider” and enter Medical Provider’s Name or Facility.
OPPM/DUEA/UXG
35
Screen Package Document – Medical CDR Application
Upon saving, the user returns to the Assistive Devices page where the table is populated with a new entry
designated by the “NEW” information status badge.
OPPM/DUEA/UXG
36
Screen Package Document – Medical CDR Application
1.12.
Other Medical Information
The user is asked to list organizations other than their providers that may have their medical records based on
the last 12 months.
If the user selects “Yes,” a blank Organizations table will appear below.
If the “Add Organization” button is selected, the Organization Details page will display.
OPPM/DUEA/UXG
37
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
38
Screen Package Document – Medical CDR Application
Upon saving, the user returns to the Other Medical Information page where the table is populated with a new
entry designated by the “NEW” information status badge.
OPPM/DUEA/UXG
39
Screen Package Document – Medical CDR Application
1.13.
Work
The user is asked to answer if they ever worked since the date of their last disability decision.
Upon selecting “Yes,” additional fields will appear below.
OPPM/DUEA/UXG
40
Screen Package Document – Medical CDR Application
1.14.
Support Services
The user is asked to list support services that they participated in since the date of their last disability decision.
OPPM/DUEA/UXG
41
Screen Package Document – Medical CDR Application
If the user selects “Yes,” a blank Support Services table will appear below.
OPPM/DUEA/UXG
42
Screen Package Document – Medical CDR Application
If the “Add Organization” button is selected, the Plan or Program Details page will display.
OPPM/DUEA/UXG
43
Screen Package Document – Medical CDR Application
If user selects “Yes, I’m scheduled to completed it,” they can provide ‘Date to be Completed.’
If user selects “No, I completed it,” they can provide ‘Date Completed.’
If the user selects “No, I stopped participating before completing it,” they can provide a reason for ending
their participation.
OPPM/DUEA/UXG
44
Screen Package Document – Medical CDR Application
The user can select services, tests, or evaluations from the checklist. If a service, test, or evaluation is not on
the list, the user can select “Other” and provide details.
OPPM/DUEA/UXG
45
Screen Package Document – Medical CDR Application
Upon saving, the user returns to the Support Services page where the table is populated with a new entry
designated by the “NEW” information status badge.
OPPM/DUEA/UXG
46
Screen Package Document – Medical CDR Application
1.15.
Training
The user is asked to list trainings that they participated in since the date of their last disability decision.
If the user selects “Yes,” a blank Training table will appear below.
OPPM/DUEA/UXG
47
Screen Package Document – Medical CDR Application
If the “Add Training” button is selected, the Training Details page will display.
OPPM/DUEA/UXG
48
Screen Package Document – Medical CDR Application
Upon saving, the user returns to the Training page where the table is populated with a new entry designated
by the “NEW” information status badge.
OPPM/DUEA/UXG
49
Screen Package Document – Medical CDR Application
1.16.
Education
The user is asked to list education that they received since the date of their last disability decision.
If the user selects “Yes,” a blank Education table will appear below.
OPPM/DUEA/UXG
50
Screen Package Document – Medical CDR Application
If the “Add Education” button is selected, the Education Details page will display.
OPPM/DUEA/UXG
51
Screen Package Document – Medical CDR Application
Upon saving, the user returns to the Education page where the table is populated with a new entry designated
by the “NEW” information status badge.
OPPM/DUEA/UXG
52
Screen Package Document – Medical CDR Application
1.17.
Daily Activities
The user is asked to describe difficulty doing various activities listed.
OPPM/DUEA/UXG
53
Screen Package Document – Medical CDR Application
Upon selecting one or several activities, the user will have to provide an explanation.
OPPM/DUEA/UXG
54
Screen Package Document – Medical CDR Application
1.18.
Remarks
The user can provide additional information on the Remarks page.
1.19.
Summary
The user will be able to review all entered information on the Summary page.
OPPM/DUEA/UXG
55
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
56
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
57
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
58
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
59
Screen Package Document – Medical CDR Application
Upon pressing the “Submit” button on the Summary page, the confirmation message will display, where user
must acknowledge that all information provided is true and correct.
OPPM/DUEA/UXG
60
Screen Package Document – Medical CDR Application
1.20.
Receipt
Once submitted, the user will be taken to the Receipt page where they can print and/or download/save their
completed continuing disability review report as well as their electronically signed permission to release
records.
Upon cliking “Done,” the user will be taken to their mySSA homepage. The option to access their Continuing
Disability Review will no longer be available.
The receipt, which is a read-only copy of the Summary, is shown below.
OPPM/DUEA/UXG
61
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
62
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
63
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
64
Screen Package Document – Medical CDR Application
OPPM/DUEA/UXG
65
| File Type | application/pdf |
| Author | [email protected] |
| File Modified | 2023-05-01 |
| File Created | 2023-05-01 |