Form SSA-536 Medical or Psychological Consultant's Review of Childhoo

MEDICAL CONSULTANT’S REVIEW OF
CHILDHOOD DISABILITY EVALUATION FORM (SSA-538)
DDS _________ SSN _________________ Name ________________________
Review of SSA-538 dated ____________

The reviewing medical consultant completes this form for any case in which there is a signed
Childhood Disability Evaluation Form (CDEF), Form SSA-538.
Use Parts I through III to record your agreement, disagreement or determination of
insufficiency with the corresponding sections I through III of the CDEF. Use Part IV to explain
in detail the evidentiary basis(es) for every disagreement or insufficiency you checked in
Parts I through III. Use Part V to document your assessment of overall severity if you
disagreed with the DDS’s assessment (or DDS’s disposition).
INCOMPLETE OR
INADEQUATE

PART I – SUMMARY

AGREE

DISAGREE

A. Impairments

_____

_______

_______

B. Disposition

_____

_______

_______

C. Assessment of Functioning
Throughout Sequential Evaluation

_______

PART II – FUNCTIONAL EQUIVALENCE
A. Domain Evaluations

AGREE

DISAGREE

INCOMPLETE OR
INADEQUATE

1. Acquiring and Using Information

______

______

_____

2. Attending and Completing Tasks

______

______

_____

3. Interacting and Relating With Others

______

______

______

4. Moving About and Manipulating Objects ______

______

______

5. Caring for Yourself

______

______

______

6. Health and Physical Well-Being

______

_______

_______

_______

________

________

B. Conclusion

Final SSA-536 draft 081503 ODPQ-CPT (collection)
Judy Hicks, ODP, ODEP, CPT
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PART III – EXPLANATION OF FINDINGS

AGREE

Explanation of Findings

_______

DISAGREE
________

INCOMPLETE OR
INADEQUATE
________

If you checked “AGREE” in every item in Parts I-III, DO NOT complete Part IV. Proceed
to Part V.

PART IV - MCS NARRATIVE DISCUSSION
If you checked “DISAGREE” or “INCOMPLETE OR INADEQUATE” in ANY item in
Parts I-III, complete this section as follows:


Provide a complete and detailed narrative discussion of the evidentiary basis(es) for not
agreeing with the DDS.



Cite the specific evidence that supports your conclusion(s) that differ substantively from
those of the DDS, or identify missing or incomplete evidence and fully explain why it is
needed.

If you provide your comments on an SSA-416 Medical Note, please check here. ___

Final SSA-536 draft 081503 ODPQ-CPT (collection)
Judy Hicks, ODP, ODEP, CPT
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PART V - MCS REVIEWER’S DISPOSITION
Complete this section only if you DO NOT AGREE with the DDS’s disposition in
Part I B.
Your assessment of overall severity:
__ Not Severe
__ Meets

Identify the listing which is met:

_______________________________

__ Medically Equals Identify the listing which is equaled:

_________________________

__ Functionally Equals
__ Does Not Meet, Medically Equal, Functionally Equal
__ Duration Not Met
__ Other: __________________________________________________________________

Medical Consultant’s Signature

Review Component

MC Code

Date

See Revised Privacy Act Statement
PRIVACY AND PAPERWORK REDUCTION ACTS: The information requested on this form is authorized
by the Social Security Act, Sections 205(a) and 1631(e)(A) and (B), and Title 20 CFR 416.989. Social
Security needs the information on this form to make a determination about the child’s continuing disability.
Giving us information on this form is mandatory. Although the information you furnish on this form would
almost never be used for any purpose other than making a determination about the child’s continuing
disability; such information may be disclosed by the Social Security Administration as follows: (1) to
enable a third party or agency to assist Social Security in establishing rights to Social Security benefits for
the child; (2) to comply with Federal Laws requiring the release of information from Social Security records
(e.g., to the General Accounting Office and the Department of Veterans Affairs); and (3) to facilitate
statistical research and such activities necessary to assure the integrity and improvement of the Social
Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social
Security).
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other Federal, State or local government agencies. Many agencies
may use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it. Explanations about these and
other reasons why information you provide us may be used or given out are available in Social Security
offices. If you want to learn more about this, contact any Social Security office.
Final SSA-536 draft 081503 ODPQ-CPT (collection)
Judy Hicks, ODP, ODEP, CPT
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12/23/2008

See Revised Paperwork
Reduction Act Statement
Paperwork Reduction Act Statement: This information collection meets the clearance 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 control number. We
estimate that it will take about 20 minutes to read the instructions, gather the facts, and answer the
questions.

Final SSA-536 draft 081503 ODPQ-CPT (collection)
Judy Hicks, ODP, ODEP, CPT
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12/23/2008

The following revised Privacy Act Statement will be inserted into the form
at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1631(e)(A) and (B) of the Social Security Act, as amended, as well
as Title 20 CFR 416.989, authorize us to collect this information. The information you
provide will be used to determine a child’s continuing disability.
The information you furnish on this form is voluntary. However, providing the
information on this form is an obligation under the terms of your contract.
We rarely use the information you supply for any purpose other than for determining the
continued disability of a child. 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, which include but
are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Medicare benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Medicare programs.
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. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 control number. We estimate that it will take about 12
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
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 form.