BBA 812 - Paper Fact Sheet - Revised

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) 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.

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

(over)
Exclusion of Certain Medical Sources’ Evidence

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

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.

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 See Revised Privacy Act
engaged to perform by SSA or State agency
Statement Attached
acting in accord with sections 221 or 1633

Social Security Administration
SSA Publication No. 64-106
June 2016
OMB Control No. XXXX-XXXX
Printed on recycled paper

Produced and published at U.S. taxpayer expense

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 208, 221, 223(d)(5)(C), 1128, 1129, 1631(e), 1632, and 1633 of the Social Security 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:



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,



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) 600089, 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 of our SORNs, is available on
our website at www.socialsecurity.gov/privacy.