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

Social Security Administration
Office of Chief Information Officer

Template:
Scheduling Text/Email Agreement
Letter and Form

T
F
Release:
A
R
<2.X>
D

1. Template Name: Scheduling Text/Email Agreement Letter and Form
2. Template Type: Letter
3. Business Definition: Obtain agreement from the claimant, parent of a minor child, or
legal guardian for SSA and the DDS to communicate appointment information via text
message and/or email.
4. Policy References:

TBD

5. Revision History
Date

Description

Author

Release

6. Correspondence Package Attributes:
Package
Attribute

Description

Notes

Description

Notes

7. Template Attributes:
Template
Attribute

8. Data table:
Attribute Name

Description

9. Key for the colors:
Example

Definition

[case_id]
[shared language]

You/He/She or [Generator
LEX]/[GeneratorLUN]
[Addressee Information]

data element
SNO, Interpreter Language, Enclosure,
Multi-Language Insert
paragraph logic. Which language to include
or not included based on the case.
pronoun or name logic.
standard content. Standard signature block,
standard footer, standard header, etc.

~ END ~
The next page includes the letter template.

OMB No. 0960-0555
[State Letterhead]
[Standard Header]
[Addressee Information]
[StandardFreeInterpreterLanguage]
[SpecialNoticeOption(SNO)]
[IntroductionReusableContent].
We are the office that makes disability determinations for the Social Security Administration
(SSA) in your state. With your permission, SSA can now text and email some messages to you
about appointment(s).
We cannot begin to text or email you without your permission, so if you would like to receive
scheduling text or email messages from SSA, please complete the attached form and return it to
us as soon as possible in the pre-addressed envelope provided. You may also fax the form to
[dds_fax#].

[Start reusable content: [IfYouHaveAnyQuestions]]
If You Have Any Questions
Please call the phone number(s) shown below Monday-Friday between [local_office_open] and
[local_office_close]. When you call or leave a message, please provide the Case ID: [case_id],
your name, [Clmt Full Name]'s name, and a call
back number.
[End reusable content: [IfYouHaveAnyQuestions]]
[Standard Signature Block]
Enclosure(s):
Scheduling Text/Email Agreement Form
Privacy Act and Paperwork Reduction Act Statements
[Multi-Language Insert]
OR
Multi-Language Insert

Return Envelope

[Standard CC Block]

OMB No. 0960-0555

[Standard Header]
{barcode}
[Addressee Information]
PLEASE COMPLETE AND RETURN
TEXT AND EMAIL MESSAGE AGREEMENT FORM
By consenting to receive scheduling text messages from Social Security, you understand that:
• You will receive “SSA Scheduling” electronic messages related to your Social Security
appointments (for example: appointment confirmations, reminders, and surveys).
•

•
•
•
•

You may not receive messages about all your appointments based on this consent. If you
later opt out of receiving messages by responding “STOP,” you will no longer receive any
SSA scheduling messages from this number.

Message frequency varies.
You can text STOP to opt-out at any time.
For help, text HELP.
Message and data rates may apply.

You can view our terms and conditions and privacy policy at https://www.ssa.gov/ensms
Please read the statements below, check all that apply, and provide the information requested.
To begin receiving reminders, sign, date, and mail this form as soon as possible using the preaddressed envelope provided. You may also fax the form to [dds_fax#].

□ I hereby agree to receive scheduling text messages from Social Security.
□ I hereby agree to receive scheduling email messages from Social Security.
_____________________________________ ______________________________________
Phone Number
Email Address

____________________________________________________________________________
(Claimant/Parent or Legal Guardian Signature)
(Date)
______________________________________
(Printed Name)

OMB No. 0960-0555

Privacy Act Statement
Collection and Use of Personal Information
Sections 221 and 1633 of the Social Security Act, as amended, allow us to collect your
information, which we will use to schedule appointments and release reminders about it.
Providing this information is voluntary, but not providing such may prevent us from providing
the requested services. As law permits, we may use and share the information you submit,
including with private medical consultants, other Federal agencies, contractors, and others, as
outlined in the routine uses within System of Records Notices 60-0044 and 60-0320, available at
www.ssa.gov/privacy. Your information may also be used in computer matching programs for
Federal benefits eligibility and to recoup debts under these programs.
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 4 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.