Exclusion of Certain Medical Sources’ Evidence

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Exclusion of Certain Medical
Sources’ Evidence
Under section 223(d)(5)(C) of the Social
Security Act (Act), we must exclude evidence
from certain medical sources unless we find we
have good cause to consider it.
Sections 404.1503b and 416.903b of our
regulations, 20 C.F.R. 404.1503b and 416.903b,
set forth when we may find good cause. They
also require medical sources that fall within one
or more of the categories listed in section 223(d)
(5)(C)(i) of the Act to abide by certain reporting
requirements, as described in this Fact Sheet.
Failure to self-report may result in referral to
our Office of the Inspector General (OIG) for
investigation and possible penalty.

Why You Received This Fact Sheet
The Secretary of the Department of Health &
Human Services (HHS) or our OIG informed us
that you are a medical source that falls within
one or more of the categories listed in section
223(d)(5)(C)(i) of the Act.
Section 223(d)(5)(C)(i) of the Act mandates
that, absent good cause, we cannot consider
evidence furnished by a medical source who:
• was convicted of a felony under sections 208
or 1632 of the Act; or
• was excluded from participating in any
Federal health care program under section
1128 of the Act; or
• was imposed with a civil monetary penalty
(CMP), assessment, or both, for submitting
false evidence under section 1129 of the
Act. Sections 404.1503b and 416.903b of
our regulations, 20 C.F.R. 404.1503b and
416.903b, define when we may have good
cause to consider these sources’ evidence.

What We Need From You
Each time you submit evidence for a Social
Security disability claim, you must attach a
written statement indicating that you are a
medical source that falls within one or more of
the categories listed in section 223(d)(5)(C)(i) of
the Act.
Please provide this statement with your
evidence regardless of whether you submit
the evidence to us directly or through a
representative, claimant, or other individual
or entity.
We will use this statement to determine whether
good cause exists to use your evidence when
determining disability. Thus, it is vitally important
that you submit this statement, and your
evidence, to us.

What Your Statement Must Include
Under our rules, your written statement must
include your name, title, basis of exclusion, and
the following heading:
“WRITTEN STATEMENT REGARDING
SECTION 223(d)(5)(C) OF THE SOCIAL
SECURITY ACT – DO NOT REMOVE”
You must also include the following information,
as it applies to your situation:
• the date of your felony conviction under
sections 208 or 1632 of the Act;
• the reason, effective date, and expected
length of your exclusion under section 1128
of the Act, and whether it was waived by
HHS’ Office of Inspector General; and
• the date of the CMP, the assessment, or
both, under section 1129 of the Act.

Where to Place the Written Statement
You should place your written statement before
the first page (but after any barcode page) of
evidence submitted as part of a Social Security
disability claim.

SSA.gov

(over)
Exclusion of Certain Medical Sources’ Evidence

Your Written Statement May Not
be Removed
No individual or entity may remove the written
statement before submitting the evidence to us.

We May Recontact You
We may ask you for more information
concerning your written statement or for
clarification of information that you already
provided.

What May Happen if You Do
Not Comply
If you do not include the written statement with
your evidence, we may refer you to our OIG for
potential further action, including investigation
and CMP pursuit.

For More Information Visit
Our Website
For more information, visit our website at
www.socialsecurity.gov/applyfordisability.
You may also call us at 1-800-772-1213
(TTY 1-800-325-0778).

Privacy Act Statement – Collection &
Use of Personal Information
Sections 208, 221, 223(d)(5)(C), 1128, 1129,
1631(e), 1632, and 1633 of the Social Security
Act (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: (1)
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, (2) 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
FR 15784 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
our SORNs is available on our website at
www.socialsecurity.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 comply with
these requirements unless we display a valid
Office of Management and Budget control
number. We estimate that it will take about 20
minutes to read the instructions, gather the
facts, and complete the written documentation
described above. You may send comments
on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send
only comments relating to our time estimate
to this address, not the completed written
documentation.

Social Security Administration
Publication No. 64-106
July 2023 (Recycle prior editions)
OMB Control No. 0960-0803
Exclusion of Certain Medical Sources’ Evidence
Produced and published at U.S. taxpayer expense