Microsoft Word - Sample BBA 812 Notification Letter

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Social Security Administration 			     Form Approved
Important Information 						      July 2023
      OMB No. 0960-0803
 
 	 	 	 	 	 	 	 	[SSA Component] 
 	 	 	 	 	 	 	 	[Address Line 1] 
 	 	 	 	 	 	 	 	[Address Line 2] 
 
 	 	 	 	 	 	 	 	[Date] 
[Excluded Entity Name/Title] 
[Address Line 1] 
[Address Line 2] 
 
We are writing to you because we have reason to believe you are a medical source excluded under section 223(d)(5)(C) of the Social Security Act (Act). You are not following the rules for submitting evidence to us as an excluded source.  If you do not comply with our regulations when submitting evidence to us, we may refer you to our Office of Inspector General (OIG) for potential further action.  This action may include an investigation and civil monetary penalties (CMP). 
 
The Regulations You Are Not Following 
Our regulations, 20 C.F.R. 404.1503b and 416.903b, impose specific reporting requirements on medical sources who were: 
 
    • convicted of a felony under section 208 or 1632 of the Act,  
 
    • excluded from participating in any Federal health care program under section 1128 of the Act, or  
 
    • imposed with a CMP, assessment, or both, for submitting false evidence under section 1129 of the Act. 
 
The information we received from the Secretary of the Department of Health & Human Services or our OIG indicates you are one of these medical sources.  Our records further indicate you are not complying with the specific reporting requirements that pertain to you as set forth in our regulations.  As an excluded medical provider, you are required to provide a written statement of exclusion.  The statement must include the following: 
 
    • Name and title of the excluded medical source of evidence, and 
    • Basis for the exclusion. 
 
As applicable, the statement must also include: 
 
    • The date of the felony conviction under section 208 or section 1632 of the Act,  
    • The reason, effective date, and expected length of the exclusion under section 1128 of the Act, and whether the exclusion was waived by the Office of Inspector General of the Department of Health and Human Services, and 
    • The date of the final decision imposing the CMP, assessment, or both, for submitting false evidence under section 1129 of the Act.   
 
We Previously Advised You of These Regulations 
 
We previously sent you Social Security Administration (SSA) Publication No. 64-106, 
“Exclusion of Certain Medical Sources’ Evidence,” at the address provided to us by either the Secretary of the Department of Health and Human Services or our OIG.  This publication explains our regulations and the specific reporting requirements you must follow.  Enclosed please find another copy of this publication.  We encourage you to read it carefully.   
 
You may also visit our website at https://www.ssa.gov/applyfordisability/medical_sources.html for additional information, including model documents that you may use to satisfy your specific reporting requirements. 
 
If You Have Questions 
 
If you have questions, you may call us toll-free at 1-800-772-1213.  If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778.  We can answer most questions over the phone.  You can also write or visit any Social Security office.  The office that serves your area is located: 
Social Security Office 
Street address 
City, State Zip 
 
If you call or visit an office, please have this letter with you.  It will help us answer your questions.  If you plan to visit an office, you may call ahead to make an appointment.  This will help us serve you more quickly when you arrive at the office.   
 
 	 	 	 	 	 	 	Social Security Administration   
 
Privacy Act Statement
Collection and Use of Personal Information

Sections 208, 221, 223(d)(5)(C), 1128, 1129, 1631(e), 1632, and 1633 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is mandatory. Failing to provide the information may result in referral to our Office of the Inspector General for further action.

We will use the information to determine if an individual is disabled or continues to be disabled under our rules. We may also share your 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 examinations or vocational assessments which they were engaged to perform by SSA or State agency acting in accord with sections 221 or 1633 of the Act; and,

    • To specified business and other community members and Federal, State, and local agencies for verification of eligibility for benefits under section 1631(e) of the Act.

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 (SORN) 60-0089, entitled Claims Folder System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR15784 and 60-0320, entitled Electronic Disability (eDIB) Claim File, as published in the FR on December 22, 2003, at 68 FR 71210. Additional information and a full listing of all of our SORNs, is available on our website at www.socialsecurity.gov/privacy.



Paperwork Reduction Act Statement
 Paperwork Reduction Act Statement
Paperwork Reduction Act Statement - This information collection (OMB. 0960-0803) 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 20 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  21235-6401.