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pdfDisability Case Selection
May 13, 2009
1
Select Case Level
May 13, 2009
2
Confirm Case Creation
May 13, 2009
3
Form Selection
May 13, 2009
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Link Folder
May 13, 2009
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CDR Information, Part 1 of 2
User has indicated claimant used other names, but has not entered any
May 13, 2009
6
CDR Information, Part 2 of 2
Other Names = Yes, but no other names entered
May 13, 2009
7
Other Names Used
May 13, 2009
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CDR Information, Part 2 of 2
Other Names = Yes, with another name entered
May 13, 2009
9
CDR Representatives
Appointed Representative = No
May 13, 2009
10
CDR Representatives, Part 1 of 2
Appointed Representative = Yes
May 13, 2009
11
CDR Representatives, Part 2 of 2
Appointed Representative = Yes
May 13, 2009
12
CDR Claims
May 13, 2009
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Contacts, Part 1 of 3
May 13, 2009
14
Contacts, Part 2 of 3
Person Completing Report = Claimant
May 13, 2009
15
Contacts, Part 3 of 3
Person Completing Report = Someone Else
May 13, 2009
16
Medical Conditions
Medical Conditions Propagated from mainframe, no new conditions entered
May 13, 2009
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Medical Conditions
Medical Conditions Propagated from mainframe, plus one new conditions entered
May 13, 2009
18
Medical Sources
Initial view
May 13, 2009
19
Medical Sources
User has indicated claimant has medical sources, but has not entered any
May 13, 2009
20
Add Doctor/Therapist, Part 1 of 2
May 13, 2009
21
Add Doctor/Therapist, Part 2 of 2
May 13, 2009
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Medical Sources
User has indicated claimant has medical sources and entered a doctor
May 13, 2009
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Add Hospital/Clinic, Part 1 of 3
May 13, 2009
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Add Hospital/Clinic, Part 2 of 3
May 13, 2009
25
Add Hospital/Clinic, Part 3 of 3
May 13, 2009
26
Tests Summary
May 13, 2009
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Test Information
No body part involved
May 13, 2009
28
Test Information
Body part involved
May 13, 2009
29
Physical and Mental Condition Information – Plan A
May 13, 2009
30
Physical and Mental Condition Information – Plan B
May 13, 2009
31
Medicines Summary
May 13, 2009
32
Medicine Information
May 13, 2009
33
Work
May 13, 2009
34
Remarks
May 13, 2009
35
SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 221(i), 223(d), 1614(a), 1631(e), and 1633(c) of the Social Security Act, as
amended, allow us to collect this information. Furnishing us this information is voluntary.
However, failing to provide all or part of the information may prevent an accurate and timely
decision on any claim filed.
We will use the information to determine eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•
To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representatives or representative payees to the extent necessary to pursue
Social Security claims and to representative payees when the information pertains to
individuals for whom they serve as representative payees, for the purpose of assisting
Social Security Administration (SSA) in administering its representative payment
responsibilities under the Act and assisting the representative payees in performing their
duties as payees, including receiving and accounting for benefits for individuals for
whom they serve as payees; and
•
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 a State agency acting in accord with
sections 221 or 1633 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 Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, and 60-0320, entitled Electronic Disability 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.ssa.gov/privacy.
SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 60
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also 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 regarding this burden estimate or any other
aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.
| File Type | application/pdf |
| File Title | Slide 1 |
| Author | 414761 |
| File Modified | 2020-01-14 |
| File Created | 2009-07-16 |