20 CFR 404.1503b(c) & 416.903b(c)

Fact Sheet – 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 set forth when we may find good
cause. They also require medical sources
that fall under section 223(d)(5)(C) 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 under section 223(d)(5)(C) of the
Act.

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 of the
categories of excluded medical sources.
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 following heading:

Section 223(d)(5)(C) 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 define when we may have good
cause to consider these sources’ evidence.

“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.
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.ssa.gov/applyfordisability] You may
also call us at 1-800-772-1213 (TTY 1-800325-0778).
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) 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, and 60-0320, entitled Electronic
Disability (eDIB) Claim File.
Additional
information and a full listing of all our SORNs
are
available
on
our
website
at
[www.socialsecurity.gov/foia/bluebook].

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.