Category II - MER Paper Submissions (subset of "MER Samples") category

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PRIMARY CARE

123 MAIN STREET
ANYTOWN DE  22222

This correspondence was formatted for mailing in an
envelope with the pages folded once.

CONFIDENTIALITY NOTICE: The accompanying material contains sensitive information. This information may be privileged and
confidential, and intended for the use of the
recipient named in this correspondence. If you have received this information in error,
please contact us immediately.

DDS 4
4496 NORTH MARKET ST

SUITE 300

PHILADELPHIA, KS 19807-1000

TEL: (555) 555-5555 Fax: (987) 654-3210

CLAIMANT: DCPS Danielle Brown
CASE NUMBER: 1401
REQUEST ID: DCM13046

Fiscal ID: 38 

June 27, 2022

PROVIDER:

PAYEE:
Primary Care

123 Main Street

Anytown, DE 22222

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Primary Care

123 Main Street

Anytown, DE 22222

Tax ID #: N/A

Phone: N/A

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TO ENSURE PROPER PAYMENT, PLEASE VERIFY PAYEE AND TAX ID INFORMATION
LISTED ABOVE AND THEN SIGN BELOW
Records can be Faxed to:
(123) 456-7945

If you are sending by Fax, place this page ON TOP of medical evidence.
If you are also sending your own invoice, place your invoice directly behind this invoice.

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When submitting your records using the Electronic Records Express (ERE), use the following: http://eme.ssa.gov. This method of
submission requires an ERE account, ID, and password. Additional information on ERE is available at www.ssa.gov/ere.
TOTAL MAXIMUM CHARGE

SERVICE

TOTAL CHARGE

[$15.00]

Medical Evidence of Record

$__________

I certify that the above service has been provided. Service provided under this authorization is to be furnished
without discrimination with regard to race, color, or national origin.
X___________________________
SIGNATURE BY OR FOR PAYEE

_____________
DATE

Confidentiality Notice: This message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged
information. If you
are not the intended recipient, or an authorized agent of the intended recipient, please immediately contact the sender at the phone number above and destroy all copies of the
original
message. Any unauthorized review, use, copying, disclosure, or distribution by other than the intended recipient or authorized agent is prohibited.

THIS IS AN INVOICE - PLEASE RETURN FOR PAYMENT.
*** INVOICE IS VOID AFTER 90 DAYS ***
FOR OFFICE USE ONLY

(Stephanie Schmidt)
FOR FISCAL DEPARTMENT USE ONLY

PAID DATE:_____________________

VOUCHER ID:___________________

AUTHORIZED SIGNATURE _______________________

DISABILITY DETERMINATIONS SERVICE

SSA

S09 Delaware DDS

SUITE 300

NEW CASTLE, DE 19720-1000

TEL: (555) 555-5555
PRIMARY CARE
123 MAIN STREET

ANYTOWN DE  22222

    Date: June 27, 2022
    Case ID: 1401
RE: DCPS Danielle Brown
AKA: Jacob Johnny Zimmermann Jr

Shahrukh Khan

DOB: February 17, 1975
Vendor Number: 100008

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We are the office that makes disability decisions for the Social Security Administration.
DCPS Danielle Brown is applying for or is receiving disability benefits due
to the following conditions: Back Injury, Cardiac
Condition, and Diabetes. This is not an authorization to perform an examination.
What We Need From You

To help us evaluate this claim, please send records covering the period of: 09/30/2019 to present.

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Include the following information: medical history, psychiatric history, clinical findings, laboratory findings, imaging reports,
treatment prescribed and the response, diagnosis, and prognosis.

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Please respond by
July 11, 2022.
We are enclosing a signed HIPAA compliant authorization for the release of medical records
and information.
Please provide a statement based on your findings. Your statement should express your opinion about your patient’s
ability to
do work-related physical and/or mental activities despite the limitations or restrictions
imposed by her medical condition(s).
For physical
impairments, these activities include sitting, standing, walking, lifting, carrying, pushing,
pulling, or other
physical activities (including manipulative or postural activities, such as
reaching, handling, stooping, or crouching); other
activities, such as seeing, hearing, or using
other senses; and ability to adapt to environmental conditions, such as temperature
extremes or
fumes. For mental impairments, these activities include understanding; remembering; maintaining
concentration,
persistence, or pace; carrying out instructions; and responding appropriately to
supervision, coworkers, and work pressures.
If you would like payment for your records, please (1) submit and sign the invoice, (2) complete and submit a W-9 forms
online per attached "Substitute Form W-9 Request" instructions and (3) submit copies of your records. This will allow prompt
payment for records you submit to Disability Determination Services. The information from the W-9 form will allow us to
add you to our payment system, which will expedite future payments for records.
If it is determined that we need additional information regarding your patient's impairments, would you be willing to perform
an examination to provide additional findings?
Please contact us if you would be willing to perform this examination. We will
assume that you do not wish to perform the examination if you do not respond.
If You Have Any Questions
If you have any questions or wish to provide more information, please call us at the number(s)
shown below Monday - Friday
between 11:30 am and 7:30 pm. When you call or leave a message,
please provide the Case ID: 1401, your name,
DCPS
Danielle Brown’s name,
and a call back number.
Thank you for your help.

1401/ Assigned 2723 L556/ DCPS / DCM13046 / OMB No. 0960-0555 / pkg-ev-1010

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S. Schmidt

(301) 555-1212

(987) 654-3210 (FAX)

1401/ Assigned 2723 L556/ DCPS / DCM13046 / OMB No. 0960-0555 / pkg-ev-1010

State of Delaware
Substitute Form W-9 Request
The State of Delaware’s Division of Accounting requires that a Substitute W-9 form be completed
online. This process is
mandatory for all vendors (payees) before any payments can be made.
Please go to this website: www.accounting.delaware.gov and select the link “W9 Form” at the bottom of the webpage.
Please complete and print a copy using your internet’s Print option or “Ctrl+P” while on the webpage. Once printed, select
“Submit”. Expect a call from our Vendor
Maintenance Team to verify your information.
For questions regarding the vendor forms, please call (302) 672-5000 and ask to speak with a member of the vendor team.
PLEASE NOTE:

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• No paper forms will be accepted in lieu of the online process. We are asking for a Substitute W9, not the Standard IRS Form
W9.

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• Please sign the Authorization and return all documents to the DE DDS.

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• Please ensure that the Tax ID/EIN is correct on our document as well as any other information. You may indicate
corrections on the Authorization for
payment invoice.

1401/ Assigned 2723 L556/ DCPS / DCM13046 / OMB No. 0960-0555 / pkg-ev-1010

Thank You

DISABILITY REPORT FORM

Jun 27, 2022

PRIMARY CARE
123 MAIN STREET

ANYTOWN DE  22222

Patient: DCPS Danielle Brown

Case ID: 1401

DOB: February 17, 1975

ALLEGATIONS: Heart condition, arrhythmia, high blood pressure, headach; blindness; copd; glaucoma; depression; back
injury; diabetes
DATE OF LAST OFFICE VISIT: __________________________________________
Reading
Ht* ____________

Date
____________ *Measured without shoes

Wt ____________
BP** ____________

____________ ** Cuff Size:
____________ (   ) Regular (   ) Oversized

(   ) Normal (   ) Abnormal – Describe In Remarks
(   ) Normal (   ) Abnormal – Describe In Remarks
(   ) Normal (   ) Abnormal – Describe In Remarks
(   ) Normal (   ) Abnormal – Describe In Remarks
(   ) Normal (   ) Abnormal – Describe In Remarks
(   ) Normal (   ) Abnormal – Describe In Remarks
(   ) Normal (   ) Abnormal – Describe In Remarks
(   ) Normal (   ) Abnormal – Describe In Remarks
(   ) Normal (   ) Abnormal – Describe In Remarks

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EENT
LUNGS
HEART
VASCULAR
ABDOMEN
GENITOURINARY
NEUROLOGICAL
MUSCULOSKELETAL
PSYCHOLOGICAL/PSYCHIATRIC

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EXAMINATION FINDINGS:
Visual Acuity __________
Corrected (   ) Y (   ) N
Field Loss (   ) Y (   ) N
Date ______________

LABORATORY AND SPECIAL STUDIES:

(   ) NO (   ) YES – Please use back of this form to give dated
results of all pertinent studies. If available, please attach a copy of EKG tracings.

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FUNCTIONAL LIMITATIONS: Please include your opinion, based on your medical findings:

(FOR ADULTS) of this individual’s ability to do work-related activities such as sitting, standing, walking, lifting, carrying,
handling objects, hearing, speaking, traveling, understanding and remembering, sustaining concentration and persisting at
tasks, socially interacting, and adapting.

(FOR CHILDREN) about the child’s functional limitations in learning, motor functioning, performing self-care activities,
communicating, socializing, and completing tasks (and, if the child is a newborn or young infant from birth to age 1,
responsiveness to stimuli).
REMARKS ON BACK: (   ) YES (   ) NO

DIAGNOSES/PROGNOSIS/DURATION

PHYSICIAN’S SIGNATURE _______________________________________ DATE_______________

1401/ Assigned 2723 L556/ DCPS / DCM13046 / OMB No. 0960-0555 / pkg-ev-1010

Form Approved
OMB No. 0960-0623

WHOSE Records to be Disclosed
NAME (First, Middle, Last, Suffix)

Gary Martin Ashcraft
SSN

508-01-1205

Birthday
(mm/dd/yy)

10/23/71

AUTHORIZATION TO DISCLOSE INFORMATION TO
THE SOCIAL SECURITY ADMINISTRATION (SSA)
** PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW **
I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange):
OF WHAT All my medical records; also education records and other information related to my ability to
perform tasks. This includes specific permission to release:
1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s)
including, and not limited to :
• Psychological, psychiatric or other mental impairment(s) (excludes "psychotherapy notes" as defined in 45 CFR 164.501)
• Drug abuse, alcoholism, or other substance abuse
• Sickle cell anemia
• Records which may indicate the presence of a communicable or noncommunicable disease; and tests for or records of HIV/AIDS
• Gene-related impairments (including genetic test results)
2. Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work.
3. Copies of educational tests or evaluations, including Individualized Educational Programs, triennial assessments, psychological and
speech evaluations, and any other records that can help evaluate function; also teachers' observations and evaluations.
4. Information created within 12 months after the date this authorization is signed, as well as past information.
THIS BOX TO BE COMPLETED BY SSA/DDS (as needed) Additional information to identify

FROM WHOM

the subject (e.g., other names used), the specific source, or the material to be disclosed:

•

All medical sources (hospitals, clinics, labs,
physicians, psychologists, etc.) including
Primary Care
mental health, correctional, addiction
123 Main Street
treatment, and VA health care facilities
Anytown, DE 22222
• All educational sources (schools, teachers,
09/30/2019 to present
records administrators, counselors, etc.)
• Social workers/rehabilitation counselors
• Consulting examiners used by SSA
• Employers, insurance companies, workers'
compensation programs
• Others who may know about my condition
(family, neighbors, friends, public officials)
The Social Security Administration and to the State agency authorized to process my case (usually called "disability
TO WHOM
determination services"), including contract copy services, and doctors or other professionals consulted during the
process. [Also, for international claims, to the U.S. Department of State Foreign Service Post.]
PURPOSE
Determining my eligibility for benefits, including looking at the combined effect of any impairments
that by themselves would not meet SSA's definition of disability; and whether I can manage such benefits.
Determining whether I am capable of managing benefits ONLY (check only if this applies)

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EXPIRES WHEN
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•
•
•
•

This authorization is good for 12 months from the date signed (below my signature).

I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.
I understand that there are some circumstances in which this information may be redisclosed to other parties (see page 2 for details).
I may write to SSA and my sources to revoke this authorization at any time (see page 2 for details).
SSA will give me a copy of this form if I ask; I may ask the source to allow me to inspect or get a copy of material to be disclosed.
I have read both pages of this form and agree to the disclosures above from the types of sources listed.

PLEASE SIGN USING BLUE OR BLACK INK ONLY IF not signed by subject of disclosure, specify basis for authority to sign
Parent of minor
Guardian
Other personal representative (explain)
INDIVIDUAL authorizing disclosure

❑

SIGN

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Electronically Signed By:

Gary Martin Ashcraft

Date Signed
07/24/19
Phone Number (with area code)
214-402-6901

(Parent/guardian/personal representative sign
here if two signatures required by State law)

Street Address
C/O UNION GOSPEL MISS 3211 IRVING BLVD
City
DALLAS

State
TX

ZIP
75247-6031

WITNESS I know the person signing this form or am satisfied of this person's identity:
Attested by SSA or Designated State Agency Employee:

SIGN

IP. T Foulke

Phone Number (or Address)
866-931-4958 DALLAS TX 75237-3867

IF needed, second witness sign here (e.g., if signed with "X" above)

SIGN
Phone Number (or Address)

This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical, educational, and
other information under P.L. 104-191 ("HIPAA"); 45 CFR parts 160 and 164; 42 U.S. Code section 290dd-2; 42 CFR part 2; 38 U.S. Code section
7332; 38 CFR 1.475; 20 U.S. Code section 1232g ("FERPA"); 34 CFR parts 99 and 300; and State law.
Form SSA-827 (11-2012) ef (11-2012) Use 4-2009 and Later Editions Until Supply is Exhausted

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Explanation of Form SSA-827
"Authorization to Disclose information to the Social Security Administration (SSA)"
We need your written authorization to help get the information required to process your claim, and to determine your capability of
managing benefits. Laws and
regulations require that sources of personal information have a signed authorization before releasing
it to us. Also, laws require specific authorization for the release of
information about certain conditions and from educational
sources.
You can provide this authorization by signing a form SSA-827. Federal law permits sources with information about you to release
that information if you sign a single
authorization to release all your information from all your possible sources. We will make
copies of it for each source. A covered entity (that is, a source of medical
information about you) may not condition treatment,
payment, enrollment, or eligibility for benefits on whether you sign this authorization form. A few States, and
some individual
sources of information, require that the authorization specifically name the source that you authorize to release personal
information. In those cases, we
may ask you to sign one authorization for each source and we may contact you again if we need
you to sign more authorizations.
You have the right to revoke this authorization at any time, except to the extent a source of information has already relied on it to
take an action. To revoke, send a
written statement to any Social Security Office. If you do, also send a copy directly to any of
your sources that you no longer wish to disclose information about you;
SSA can tell you if we identified any sources you didn't
tell us about. SSA may use information disclosed prior to revocation to decide your claim.
It is SSA's policy to provide service to people with limited English proficiency in their native language or preferred mode of
communication consistent with Executive
Order 13166 (August 11, 2000) and the Individuals with Disabilities Education Act.
SSA makes every reasonable effort to ensure that the information in the SSA-827
is provided to you in your native or preferred
language.

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Privacy Act Statement
Collection and Use of Personal Information

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Sections 205(a), 233(d)(5)(A), 1614(a)(3)(H)(i), 1631(d)(l) and 1631(e)(l)(A) of the Social Security Act as amended, [42 U.S.C. 405(a), 433(d)
(5)(A), 1382c(a)(3)(H)
(i), 1383(d)(l) and 1383(e)(l)(A)] authorize us to collect this information. We will use the information you provide to help
us determine your eligibility, or continuing
eligibility for benefits, and your ability to manage any benefits received. The information you
provide is voluntary. However, failure to provide the requested
information may prevent us from making an accurate and timely decision on
your claim, and could result in denial or loss of benefits
We rarely use the information you provide on this form for any purpose other than for the reasons explained above. However, we may use
it for the administration and
integrity of Social Security programs. We may also disclose information to another person or to another agency
in accordance with approved routine uses, including but
not limited to the following:
a) To enable a third party or an agency to assist us in establishing rights to Social Security benefits and/or coverage;

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b) To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office, General Services
Administration, National Archives Records
Administration, and the Department of Veterans Affairs);
c) To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and
d) To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of our programs (e.g., to the U.S. Census
Bureau and to private entities under contract
with us).
We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept
by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a person’s eligibility
for Federally funded or administered benefit
programs and for repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses of the information you gave us is available in our Privacy Act Systems of Records Notices entitled, Claims
Folder System, 60-0089;
Master Beneficiary Record, 60-0090; Supplemental Security Income record and Special Veterans benefits, 60-0103;
and Electronic Disability (eDIB) Claims File, 600340. The notices, additional information regarding this form, and information regarding our
systems and programs, are available on-line at www.socialsecurity.gov or
at any Social Security office
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
provide this information unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0555. We estimate that it will take
between 5 to 30 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 212356401.

Form SSA-827 (11-2012) ef (11-2012)

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