Addendum

Explanation Change Worksheet

HA-66 Request for Evidence from Doctor

&

HA-67 Request for Evidence from Hospital

20 CFR 404 Subpart P and 20 CFR 416 Subpart I

OMB No. 0960-0722

We are submitting this collection as a revision to document that we now receive the medical evidence requested electronically. With the advent of the electronic disability folder and Electronic Records Express (ERE), providers of medical evidence of record now have the ability to submit records directly to hearing offices electronically. This is done utilizing the following URL: http://eme.ssa.gov. Hearing offices will continue to mail the HA-66 and/or HA-67, as appropriate, for each medical source from which they request evidence. Based on the experience hearing offices have had to date, we anticipate approximately 25% of respondents will take advantage of electronic records submission.

No other changes were involved.

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