BBA 812 - Internet Fact Sheet Screen Shots - Revised

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Social Security

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Apply Online For Disability Benefits
Soc ia l S ecurirty offers a n o nlin e d is,a b ility a pplicatio n you can complete at your
conv,e n ie n ce. Apply from t h e comfort o f your- home o r a ny locat io n a t a t im e most
conv,e n ie nt fo r yo u . Yo u do n ot n eed to d riive t o y o ur loca l Social Security office or w a it
fo r ,a,n appointment w itlh a Socia l Security riep rese ntative .

>W ho can apply fo r a dult

I)

Pub Iicatio n:s
Apply O nlin e fo r Disab ility Be n efit s ),.
Disability Be n e fits .)

disab ility b enefi ts on lin e ?
Fa ct S heet - Excl usion of C e r-ta in
Med ic a l Sourc es' Evidence ),..

How d o I a pply for b enefi ts ?

R.el!ated linformati'on,

> W hat info.-mat io n d o

I)

I need to a pply fo r benef its?

Disability P lann e rl nforn,a t ion for Representatives

W hat docum ent s d o I n eed t o provid e ?
W hat You Need t o Know Abo u t Th e
O nlin e Disability A pplicatio n

>W hat a re t he a dva ntages

of a pplying using our o n line d isab ility a pplic ation

Help in g Som eon e App ly O nline

p ro ces s?

i nforma t io n o n Exd ud ing Ce rta in
Med ical Sources· Evidenc e

I)

W hat ha ppe n s after I ap p ly?

I)

What about SSI1

W hat o t h e r w a ys c a n I app ly?

7

Note,

Sele ct " Ret urn to a Saved A pp licatio n " if before Ja n ua ry 25, 2014, you started b ut
d id not f inish :
• An Applicat io n fo r Disab ility Be ne fit s a nd ha ve a n · App licatio n
• An "Adult Disab ility Re po rt~ a nd ha ve a MReent ry N umbe r-."

a nd c h ild re n w irth Ii m it ed income
a nd re sou rces.
Lear-n More...

umbe rt or-

O nce you enter y o u r "App licatio n Nlumbe.r" o r "Reentry um ber" a nd you r Socia l
Sec ur-ity N umbe r, y o u w ill re t urn to yo ur- saved info rmatio n .

Apply fo r Disability

Return to a Saved Application

Check App lication Status

Acc e ssib il ity - FOIA · Open Govenunent - Glossary · Priva cy ·

J

S u pp le m e nta l Secu rity In come (SSI)
p a ys ben e fi t s to dis,able d adults

port Fra ud. waste o r Abuse - S ite M a p · Wel:Js ite. Pclicies

Benefits-gov - D is.abirrty.!JC" - l-lealthcare.gov - MyMo ney.g-av - Regulatio ns,.gov - U SA-gov - Other GcYe mme n.t Sites

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Social Security

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Information On Excluding Certain Medical Sources' Evidence
0MB Control No. XXXX- XXXX

Publications
Under sectio n 223 (d )(5)(Q (i) o f th e Socia l Sec urity Act (Act), we m u st excl ude e vid e nce
fro m certain m ed ica'I :Sources un less we fi nd w e ha ve good ca use to con s id e r it.
Sectio ns 4 04.150 3b a n d 4 16.903b o f o ur reg ul a t io n s, 20 C.F.R. §§ 4 04.150 3 b a nd
4 16.903b, set forth whe n w e may find good cause. The y a lso req u ire m ed ical so u rces
t ha t fa ll w it hin o n e o f t he categorie s list e d in ,;ectio n 2 23{d }(S)(Q (i) o f th e Act to ab ide
by certa in re p orting req u ire m e nt s.
Fa ilure t o se lf- re po rt m a y res u lt in referra l to o ur O ffice of t he In s p ect o r Ge n e ra '! (O IG)
fo r invest igatio n a nd possib le pena lty .

Note

The re q u irements exp la ine d o n t h is webpage a nd t he d o w n loadable Fact S h eet
ap p ly to m ed ical sources t ha t fa ll w it hin o n e of t h e categor ies listed in sectio n 2.23
(d )(S)(C)(i) o f t he Ac t. The o n ly re q u irement tha t a lso applies to ind iv id u a ls
ap p lyin g for o r receiving Socia l Secu rity d isab ility be n ef its or pa y men t s, a,nd th e ir
re p rese ntat ives, is t ha t th e y m ust not remove a medic.a l source's. w ritte n stateme nt
(th e state m e nt t hat ind icates t h e source fa lls w ith in o n e o r more o f th e cat ego ries
list ed in sectio n 223(d )(S)(C)(i) o f t he Act) b efore submitting e v id e nce fro m th a t
m ,e d i-ca l s.ource to u s.

Apply Online fo r Disabil ity Be n e fits )...
D isabili ty Benef its )...
Fact Sheet - Exclu sio n of Certa in
M e d ical Sources' Evid e nc e ),..
M o d el W rit ten St at ement fo r M edical
Sources Fall ing unde r Sectio n 208 o r
1632 of t he A ct ).
M odel W ritte n Stat ement fo r M edical
Sources Fall ing Und e r S e ctio n 1128 o f
th e Ac t ).
M o d el Writte n St at ement fo r M edical
So urc e s Fall ing Under S e ction 1129 o f
th e Act ).

Related Information
D isa b ili ty Pla nn e r

I)

Background

W hat You Need to Know Ab o ut The
O nlin e Disability A p p licatio n

) W hat W e Need from a Med ical Source that Falls Within O n e o r M ore o f t he
Ca t e gor ies Listed in S e ctio n 223(d )(S)(C) (i) o f th e Act

I)

W hat th e State m ent Sh ou ld Inclu de

I> W he re to Place the Written Statemen t

I)

l nfo nna t io n fo r Rep resenta tives

The Written Sta tem e nt Ma y Not be Remove d

> We M ay

Recontact a Med ical So urce t hat Fa lls Within O n e o r M ore of t he
Ca t e gor ies Listed in Sectio n 223(d )(S)(C) (i) o f th e Act

) W hat M ay Ha p pen if a W r itten Statem en t is not Prov id e d

F

Th e re are Additio n a l Q u estio ns

) Privacy Act State ment - Co llectio n & U,;e o f P e rso na l Infor matio n

I>

Paperwor k Re d u ction Act Sta t e ment

H e lp ing So m e o n e Apply O n lin e

What about SSP.
Su p p le m e n ta l S e c uri ty Incom e (SSI)
p a ys ben ef its t o d isab led a d ult s
and ch ild ren w it h lim it ed incom e
a n d reso urces.
Lea r n M o re ...

~ MV Social Secl.ll"itv- - Si em, In or Create

Fa ilu re t o self- .-., port may re s ult in refe rral to o ur O ff,ic e o f t h e lnspe<:t o r G e n e ra l (OIG )
fo r inv est ig.at io n a n d p o ssib le p e n a lty.
N ote
T h e requirem e n t s expla in e d o n t h is webpage a n d t h e down loadable Fa c t S h eet
a p p ly t o med ic a l sourc e s t h a t fa ll w it h in o n e o f t h e cat e gories liste d in s e ct io n 223
(c:ll(S)(C)(i) of t h e Act T h e o n l'y requirem e nt tJh a t a lso applie s t o in d iv id u a ls
a p p lying fo r o r .-.,ce iv in g Social Security d isab ility b e n efits o r paym e nts, and t h e ir
.-.,pre sen tativ es, is t h a t the y m u st n ot remov e a m e d ical sou rc e ' s w riitte n stateme n t
(th e state me·n t t h a t in d icates t h e s.o urc e fa lls w ithin o n e o r mo re o f the categorie s
lis t e d in s e ctio n 223(c:ll(S)(C)(i) o f t h e Act.) befo,,e s u bm ittin g eviden c e tirom tha t
medica I s o urce t o u s .

M o d e l Written Stat e m e nt fo r Mled ic a l
Sou rces Fa ll ing u n der Sectio n 208 o r
1 632 of t he A ct .J...
M o d e l Writte n St at e m e nt for Mled ical
Sou rces Fa ll ing Un d e r S e ction 1 1 2 8 o f
t h e Act .)..
M o d e l Writte n St at e m e nt for M ed ical
Sou rces Fa ll ing Un d e r S e ction 1 1 2 9 o f
t h e Act .},..

Refat.ed linfo rm ar:ti o n
D is.ability P la n n e r

..., Bac lc:ground
T h e S,ec re t a ry o f tlhe Dep artme,n t of ea ltlh & H uma n S.e rvices (HHS) o r o ur O IG
infonns u s o f med ica l sou rces t h.at fa ll w it h in o n e o f t h e cat egories listed in s e ctio n
223(d)(5 )(C) (i) o f the Act.
S e ctio n 223(d)(S)(C)(i) o f t h e Ac t man dat e s t h a t , abse n t good cau se, w e canno t
c o n s id e r ev id e n ce f u rn is h ed b y a m e d ica l source W h o :
• w as convicted o f a fe lo riy unde r s e ctions 2 0 8 o r 1 6 3 2 o f the A.ct; o r
• w as e xclu d e d from p a rtic ipatin g in a ny Fe d e ra l h e a lt h care p rogram under
s e ctJio n 1 12 8 o f th e Act; o r
• w as impose d w itlh a c·iv il m o netary p e ria lty (C M P), asse ssmen t, o r b o th , fo r
su b m irttin g fa lse e v iden ce u nde r sectio n 1129 o f t h e Act.
Sectio n s 404.1503b a n d 416.903b o f o ur re g u lat io n s, 20 C.F.R. '.§,§ 404.1 5 0 3 b a n d
4 16.903b, d e fi n e w h e n w e may h a v e good cau s e to co n s ider these sources' e v id e n ce.
Spe c ifically. w e may h a v e good ca u s e t o con s id e r eviden ce · f urnis h e d b y t h e se
sou rces w h e ,n :

1 . t h e e v iden ce covers tre a t ment t h a t occur.-.,d befo .-.,, th e sourc e ' s fe lo ny
convictio n u nd e r s ect io n 2 0 8 o r 1 6 3 2 o f t h e Act,
2 . tlh e e v id e n ce covers treatmer,t t h a t occur.-.,d whe n t h e sourc e w as ri ot excl u d e d
from p artic ipat ing in a ny Federal h e a lth care p rogram under sectio n 1 128 o f t h e
Act,
3 . tlhe e v id e n ce covers treatme n t t h a t occu rred b e fo re th e souro e receiv ed a fi n a l
dec is io n imposin g a CM P, assessmen t, o r bot h , fo r s u bmit t ing fa ls e eviden ce ,
under sectio n 1129 o f the Act,
4 . tihe sole ha s is fo r tlh e e xclu s io n o f t h e s.o urc e ' s e v iden c e uride r s e ctio n 223(d)(5)
(C)(i) o f t h e Act is th a t tlh e so urce c a n n ot partic ip ate in a ny Fe derail h e a lth care
p rogra m under sect io n 1 12B o f tlh e Act , b urt the Offic e o f l'ns p ecto r Ge n e ra l o f
HH S g ra n ted a w a iv e r of t h e se<:t io n 1 12 8 excl u s io n. o r
5 . tlhe e v id e n ce is a laborat o ry fii nding(s ) about a phys ica l impairme n tJ(s ) a n d tlh ere
is n o in d ication tlh at t h ,e fi n d i n g (s ) is unrelia ble .

l nfonma t ion for Re p re sen t ativ e s
W h at Yo u Ne e d to Know Ab o u t T h e
Onlin e D is.ability A p plicatio n
He lp in g So m e o n e App ly O n lin e

What .a b out S SE

S upp le m e n t a l Security In come (SSI)
p a ys b e n e fi t s t o d isabled a d u lt s
a n d c h ild re n wirth lim it e d in come
a n d re sources.
Lea r n M o re ....

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0MB Cont rol No. XXXX-XXXX

Pub I ic;atio
Under section 223(d)(5)(C)(i ) of t h e Soc ia l S ecl.lrity Act (Ac t ). we ml.1s t e xclu de ev,id e n c e
fTom certain medica l s·o u rce:s u n less \Y e fi nd \Y e h a ve ,good cau s e to con s ide;r lrt.
S e ctio n s 404. 15-036 a n d 4 16.9036 o f o ur r e gu lat io n s • .20 C.F . R . §,§ 404 .1 5 0 3 6 a n d
416.903b. set f orth wihe,n w e may fi n d good cau se. Tlhey a l.so req u 1ince rned ical sou ,rces
tlhat f a ll w itlhin o n e of t h e cat e gories list e d in sectiio n 223(d ) ( 5 ) (C)(i) o f the Act tJo ab ide
b,y certain r eportin g r e qu l re1me n "t:s .
Fa ilure 1:o seH-report m a y r esult in .-efer r a l to our Offic e of t h e Jn s p e-ct o .- Gen e .-a l (O IG)
fo .- investigat io n a n d possi b le pen a lty.
IN oil:e·

T h e requi.-emen t s e xpla ine d o n t h is webpage a n d th e do wn loadable Fac t S h eet
ap p ly to m ed ic a l sou.-ces t h at f a ll w it h in o n e o f t he categori es. liste d i n s ectio n 223
( d)(S )(C){i) of t h e Act:. T h e o n ly r equirement tlha t a ls o app lies to ind iv id l.la s
a pp lying f o .- o r .-ecei v i ng Socia l Security d is.ab il ity ben efits. o .- paym e nts _, and t h e i.rep r esen tatives,. is . t h at the y 1m u st not remov e a m e d ical source' s w r lrtte n stateme n t
(the state m ent t h a t i n d icates t h e sou rce f a lls w ithin o n e o r mo re o f the cat egor ies
lis t e d i n section 223(d)(5 )(C){i) of t h e A ct) b efo,re s u bm itti n g ev,ide n ce firom th a t
medic.a I s o ur c e t o u s .

MIS

Apply O nli n e fo .- D isab ility B e n efit s ,)...

D i.sabil ity Ben efits ,,)...
Fa ct Sheet - E>.
M odel W ri tten S t ate m.e n t fo r M ed ica l So u rce.s F a llin g Unde r Sect-o n 1 129 o f the
Act ..J..

Help i n g Someon e A pp ly O n line

Wha1: about SSI?

S u pp leme rnta l S e c ur ity I ncome (SSI)
pays benefits t o d isabled ad ult s
a n d c h ild r e n w irt h limited in come
a nd r esources.
Lea.-n M o re, ..

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l .fv Socia l Securitv - Sie n In cw C1reat:e

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Soda I Secu r-ity

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Information On Excluding Certain. M ,e dical Sources ' Evidence
0MB Cont.-ol No,. XXXX-XXXX

PILI b I ic:atio n!S
Unde r section 223(d)(5)(C)(i) o f t h e Soci a l S ecurity Act ( Act). we m u st e xcl u de evide n ce
f.-om certain medica l sou rces u n less w e find w e h a v e good cau se to con side r iit.
Sectio n s 404.1 503.b and 416.903b of o u.- reg u l""1:ion &. 20 C.F.R. §§ 404 .1 503b a nd
4 1 6 .903b, set fort h w h en w e m ay find good cau se. T lhey a ls o .-eq u i re med ica l sou rces
t h a t fa ll w ith in one o f t h e cat ego.-ies listed i1n sec tiio n 223,(d)( S )(C)(i) o f the Act to abide
by ce,rt<>in re portiing r e qu ir eme n t s .
Fa ilu.-e to self-.-eport rna y resu lt in .-eferra l to our Office of t h e Ins p ect o r- G e n e r-a! (OIG )
fo,r investigat io n a n d p oss ib l e pen a lty.

1No1:,e ·

The r equ i.-em e n t s expla in ed o n t h is webpage a n d t h e dow n loadable Fact S h eet
app ly to med ical s.ou .-ces t h at fa ll w ithin o n e of t he catego11ies listed in section 223
(d)(S )(C){i) of the Act. T h e o n l'y r equ ir e m e nt th at a lso applies to indiv id u a ls .
app lying fo .- or .-eceiving Social Securi ty d isab il ity benef its o .- payments. and t h e i ..-ep r esentatives. is t h at th e y must n ot 11emove a medical source' s w ritte n statemen t
(the stateme·nt t h a t in d icatles t h e so urce f a Ils w ithin o n e o r rno re o f the categor ies
listed in sectio n 223(d)(5 )(C){i) o f t he A ct) b efore s u bmittin g e vi de n ce firom tha t
medica I source to u s .

Apply O nli n e f o r D isability B e n e fit s .,J,...
D is.ability B e n efit s _.A...
Fact Sheet - Exel usio n of C e .-ta in
Med ical S o urces• Evidence .)...
Mode l Writt e n S t ate.-11e nt f or· Med ical
S.ou rces F a ll ing u n der Sectio n 208 o .1 632 of t he A ct _.A...
M ode l Writt e n S t ate.-.-. e nt f or M ed ical
Sou rces F a ll ing Un d e r- Section 1 128 o f
tih e Act A
M o d e l Writt e n S t ateni e nt f or M ed ical
Sou rc es Fa ll ing Un d e r- Section 1 129 o f
tlhe Act .,J,...

R .e l!at.e d linfo.-mation
D isability P la n n e .-

> Ba c lcg ,-ound
> What We

Nee d f.-o m a M edical Sou rce t ha,t F a lls W it h in O n e or M ore of t h e
Cat e go.-ies L iste d in S e ction 223(dl) (5)(C) ( i) of t h e Act

I.._. What t h e State ment S h o u Id Incl u de
Under o u.- ru les. m edica l sou .-ces t h a t f a ll w ithin o n e or mo re of the catiegor ies l1istied
in sectio n 223,(d)(S )(C)(i) o f the Act m u s t inclu de their n a m e . title . b asis o f e xclus io n .
a n d t h e fo ll owin g head ing :
" W'RTITEN STAT EMENT REGARDIIN .G SECTION 223(d) (5)(0 OF T IHE SOCIAL
S IECUIRITY .ACT - DO NOT REMOVE -

T h ey must a lso in clu d e t!he f o llowing in i orrnatJio n , as it a p p lies to the ir s.iru a tio n :
• t!h e dlat e of t h e fel o ny cJD n victi o n unde r sect i o n s 208 o r 1 632 o f t h e Act,.
• the r eason . effective datle, a n d e xp ect ed! le n gth o f t!he e xcl u s io n u n de r s ecbio n
1 1 28 o f t h e A ct, a nd w:hetlhe ,r it w as w a ive d by HH S ' Office o f I n.specto r Gen eral,
a nd
• the dlate of t h e CMP, assessment; o .- bot h, u nde .r sect io n 1129 of t h e Act.

[ nfomiati on f or R ep r e sen 't.atives

W h at You N e e d to K no w · A b o u t T h e
O nline D is.ability Applicatio n
H elpin g Som e o n e A p p ly Online

Wha1: about SSI?

S L.l pp le m e n tal Secu r ity I n-come (SSI)
p a ys ben efit s t o disabled ad u lt s
a n d c h ild re n \viit h Ii rnited i ncome
a n d r e sources.
Lea.-n M o re ...

(1;11

Mv Socia l Securitv - Sien In

01"

Cl"eate

: 8 : : Sodal Security
:_

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,:21 SIGN I N , UP

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Information On Excluding Certain Medical Sources' Evidence
0MB Gonti-ol No,. XXXX- XXXX

PiUbl ication,s
Und e r sectio n 223 (d )(S)(C) (i) o f th e S.oc ia l Secu rity Act (Act ). w e must exclud e e Viidence
fTom c ertain medica l siou rces u n less w e find w e h a v e goo d cause to cons ide r it.
S e ctions 404.1503b a nd 4 1 6 .903b of o ur- reg u latio n s, 20 C.F.R. §§ 4 04 .1503b and
4 1 6 .903b. set fort h whe n w e rna y find good cau se. T'h e y a lso requi re med ica l sou rces.
th at fa ll w ith in o n e of t he categoi-ies liste d in sectiio rn 223(d)(5)(C)(i) o f the Act to abide
b y certain reportirig re quire m e nts .
Fa illui-e t o seilf- i-eport m a y result in referra l to o ur Office of t he Inspector- G e n e r-a l (O IG)
fo r inv estigat io n a n d possrib le pen a lty.
Note

The requ irem e n ts expla in ed on t h is webpage a nd t h e downloadable Fact S h eet
app ly to med ical soui-ces that fall w ith,in o n e o f th e cat egoi-ies listed in section 223
(d)(S)(C){i} of the Act. T he o n l'y requ i.-em e nt tlhat a lsio applies to indiv id u a ls
a p p lying fo r- or i-eceiv in g Social S,e curity d isabil,ity ben e f its o r- paym e nts. a n d th e i.i-epresentatives, is that the y m ust n ot .-e·move a m ed ical sou rce' s w ritte n stat ement
(the statement t h a t in d icates t h e so urce fa lls w ithin o n e o r mo re o f the categories
listed in sectio n 223(d)(5 )(C){i} of the Act) befo re s ubmiittin g evidence firom tha t
med ica l sou rce t o u s.

Apply O nli n e fo rr Disab ility Be n e fits .)..
D is ability Be n efit s A
Fa ct Sheet - Ex clus io n of C e rtain
M ed ical So urc e s ' Evi dence J..
M o d e I Written St ate m e nt fo r M ed ical
Sources. Fall ing under Secti o n 2 08 o .1 63.2 of the Act .J..
M o d e I Writte n St at e m e nt fo r M ed ical
S ources. Fa ll ing Unde r- S e ction 1 128 o f
the Act .)..
M o d e l Written St atem e n t fo r M ed ic a l
S ou rces Fall ing U nde r- S e ction 11 2 9 o f
the Act .)..

Re at.e d fnform.artion
D isability P la n n e i-

I> Bad ::gii-o und
> W hat W e

N eed fr-om a M edical Sou rce t ha,t Fa lls W it h in O n e or M o rre of t h e
Cat e goi-ie.s Lis t e d in S e ction 223(d )(5 )(C) (i) of t he Act

I>W hat the Stat e ment S h o u ld Incl u de
V Where to P lace the \l1fritten Statem e n t
M ed ical so u,rces t hat tam w it h 1i1n one o rr m o re o f tll-'l e catego ri es I isted in sectio n 223 (d )
(S)(C)(i) of t h e A ct s h oul d p l.ace the ir- w ritten stat e m e n t b efore t h e fi rst pag e (burt
a ,f te r a ny b a i-cod e p.a.ge) o f e viden ce tlh e y sulbmit as part of a Socia l Secu1rity d isab:ility
cla im .

~n fo .-ma ,t io n for Re pre sen tativ e s
W hat You Ne e d to Know Ab o u t T h e
O nlin e D isab ility A pplicati o n
Help in g Som e o n e App ly O n line

What about SSI?
Su p p leme n tal Secu rity In come (SSI)
pays be n efits t o d isabled adu lt s
a rid c h ildren wirl: h lim it ed incom e
a rid resou rces.
Le a i-n M o re ...

~

Mv Socia Secu:ritv - Sie n In .,.. Crea te

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~ ~

Information On Excluding Certain M ,e clical Sources' Evidence
0 M B Gontr-ol N o ,. XXXX-XXXX

Piu b Iicatio ns
Und e r sectio n 223 (d ){5)(q(i) of th e S o cia l S e c u rity Act (Act). we m u s t e xclu d e eviid e n c e
from c e rta in m e d ica l so u rces 1LJ1n less w e find w e h a v e good ca us e to con s id e .r it.
S e ctio ns 4 04.1 503,b a nd 4 1 6 .9 0 3,b of o ur re gula t io ns, 2 0 C.F. R. §,§ 4 04 .1 5 0 3 b and
416.903 b. set fort h w h e n w e m a y find good cau se. Th e y a ls o req u ire m ed i-c al s o u rces
t1hat fa ll w itlhin o n e o f t he Gate gm1ies liste d ir1 s,ectiio n 223,(d )(S)(C)(i) o f the Ac t to ab ide
by ce rtain re p ortir1 g re quire m e n ts.
Fa ilu re t o sel f- repo rt m a y result in referral to o u r O ffi c e o f t h e Ins p ect o r G e n e ra l (O IG)
fo r investigat io n and p oss ib le p e n a lty.

Note

T he re q uirem e n ts exp la in e d o n t h is w ebpage a,n d t h e down load a b le Fact Sh eet
a p p ly to m ed ic a l s,ourc e s t ha t fall w it h in o r1e of t h e cat e goriie s liste d in s e ctio n 223
(d)(5 )(C)(i) of t h e Act Th e o nly re q u ire m e nt tha t a lso a pplie s t o ind iv id u a ls
a p p lyin g fo r o r receiv ing Social Security d isa b il ity ben e fits o r paym e nts, a nd th e ir
represe n tat ives, is th.at the y m u st n ot remov e a m e d ical s o urc e ' s w rirtte n s tat e m e n t
(the s tat e m e n t t ha t ind icates t h e so urc e fa lls w ithin o n e o r m o re of the c a tegories
lis ted in s e ction 223(dl(5)(C)(i) of t he Ac t) b e fo re s u b m ittin g e v idence from that
m e d ica l s o urce t o u s .

Apply O nlin e fo r- Disab ility Be n e fit s ),..
Disab ility Be n e fits )...
Fact Sheet - Excl u s io n of C e rtain
M ed ical So u rces' Evidence
M o d e l Written State m e nt fo r M ed ical
Sources Fa ll ing under Sectio n 208 o r
1 632 of t he A ct A
M o d e l Written Stat e m e nt for M ed ical
Sou rces Fa ll ing Unde r S e ction 11 2 8 o f
the Act ),..
M o d e l Written Stat e m e nt fo r M ed ical
Sou rces Fa ll ing Unde r S e ction 11 29 o f
the Act ),..

R.ellate d Informatio n
Disability P lann er

I)

Ba c llc:g mun d

> W hat W e N eed rro m a Medical Sou rce t ha,t f a lls W ithin O n e or M ore of t he
Cat e gor ies List e d in S e ction 223(d) (5)(Q (i) of the Act

ll"l fo rima t io n for Rep re sen tative s
W hat Yo u Nee d to Kno w Abo u t Th e
O n lin e Disab ility A p plicatio n
Help in gi So m e o n e App ly O r1lin e

I ) W hat til e Stat e ment Sh o u1ld Incl u de

W h at about SSP.

I> W here to P lace t he Written St atem e n t

S upple m e n t a l S e c urity In co m e (SSI)
p a ys b e n e fi t s t o d is a b le d a d ults
a nd c h ild re n wit h limit e d in com e
a n d resou rces .

V The Written Stateme n t M a y Not b e Remov e d

No ind ivi dua l o r e ntilly m a y 1re m o v e t he w ritte n statem e r1 t b e fore su b m itti ng t h e
e V1id e nce t o ILi s .

Lea r n M o re ...

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Mv Socia Secu:ritv - Siem In

Baclk:g.-ound

l n f o rrn at io n fo r R ep resen tat iv e s
W h a t Yo u Nee d to Know A b o u t T h e
O n lin e D isab ility A p plication

> W h a t W e N eed fr-om a M edical Sou rce t h a t F a lls W it h in O n e or M o .-e o f t h e
Cat ego .-ies List e d in S e ction 223( d0(5)(C) ( i) o f t h e Act

I>
I

W hat th e Sta,t e ment S h o u ld Jncl u d e

> W her e to P la c e t he Written Sta tieme n t

> The

\IV.-ittien S t atem e n t M a y Not b e Re moved

..,, W e M a y Reco n t a ct a M e d ical S o urce t hat Falls W it h in O n e o r M ore of t he
C a t ego.-ies List e d in S e ction 223( d ) (S)(C)(i) o f t h e Act
W e may ask m e d ica l sourc es t h a t fa ll with in o n e o .- mo r e o f t h e cate gories lrste d in
s ectiion 223(d )(5 )(C) (i) of the Act fo .- m o .-e iinfo.-m a t i·o n c o n c e m in g t h e ir- written
state men t o r fo .- cla rific a t ion of infon natio n that the y a lr e ady p.-ovide d .

Help in g Som e o n e App ly Onlin e

What ,a bout SSI?
S u pp le m e n t a l S e cu r ity Incom e (SSI)
p ays b e n e fi t s to d isa b le d ad u lt s
a n d c h ild r e n w it h lim it e d income
a n d r e sou r oes.
Lea.-n M o re ...

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Information. On Excluding Certain Medical Sources' Evidence
0MB Contr,o l No. XXXX-XXXX

Pub l ications
Under sectio n 223(d}(5)(C) (i) o f the Soc ia l Security Act ( Act), we m u s t exclu de e v id e n ce
from certain medica l sou r,c e.s u n less \Ye find .,,.,e h a v e good cau s.e to con s ide r irt.
S e ction s 404.1503,b a nd 4 16.903,b o f o ur r e gu la t io n s, 20 C .F . R. !i§ 4 0 4 .1 5 0 3b a n d
416.903b, set f orth w h e n w e may find good cause. They a ls o requ,i re med ica l sou rces
th a t fa ll w itJh in o n e of t h e categories liste d in sectio n 223(d)(5)(C) (i) o f th e Act to ab ide
by ,c erta i n r·e portin g re qu ire .m e n t s .
Fa ilu re t o sellf-report m a y r esult in refer ral to ou r O ffi ce of t h e Inspect o r G e n e r a l (O IG}
f o r in v est igatio n a n d p oss ib le pen a lty.

T h e r equ irem e n t s expla in e d o n t h is webpage a n d t h e dow n loadable Fact S h eet
a pp ly to med ical sources t h at fa ll w it h in o n e of the categories liste d in section 223
(d)( S)(C)(i} o f t h e Act. T h e o n ly r equ ir ement tJh at a lsoo app lies to ind iv id u a ls
app lyin g f o r o r receiv in g Social Securi ty d isab il ity ben efits or payments , and th e ir
repr esen t.a t iv es ~ is that th e y must not remove a m e d i cal sou r ce ' s w r itte n stateme n t

(the statemen t t h a t in d icates t h e S-o -u rc e fa lls. w ith in o n e o r mo re o f th e categories
listed in sectio n 223( d)(S) (C)(i) o f t h e Act) b efo re subm ittin g e v ide n ce f rom that
medica I s o urce to u s ~

Apply O n li ne fo r Disability Be n efit s A
D isabili ty Ben e fits A
Fact Sheet - Exel u s io n of C ertai n
M ed ical Sources' Evidence A
Mode l Writte n State IT1 e nt f or M ed ical
Sou rces Fa ll ing u n der Secti o n 208 o r
1 63 2 of t h e A ct ),..
Mode l Writte n State IT1 e nt f or M ed ical
Sou rces Fa ll ing Unde r Section 1128 o f
th e Act A
Mode l Written StateIT1 e nt f or M ed ical
Sou rces Fa ll ing U n de r Section 1 129 of
t h e Act A

Rel at.e d Info r matio n,
D isability P la n ner

I>

l n fo rn,ati on for R epresent ativ es

Back g round

W h at You Nee d to Know About T he
O n li n e D isabili ty A p plicatio n

> What W e

Need from a Medical Sou rce t hat Fa lls W it h in O n e or M ore of t he
Categor ies Listed in Section 223(d)(5 )(C)(i) of t h e Act

Help in g Someon e App ly O n li n e

I>What the Statement S h ouldi Incl u de

What about SSI?

I > W here to P lace the Written S tatem e n t

S u pp leme n t a l Secu r ity In come ( S SI)
pays ben e fits t o d isabled ad u lt s
a n d c h ild r e n w ith li m it ed income
a n d resources.

> The Written S t atem e n t

M ay Not be Re moved

>We

May Reco ntact a M ed ical Source that Fa lls W it h in O n e or M ore of t he
Categor ies l ist e d in Section 223(d)(5 )(C)(i) of the Act

V What May H appen tf a W r itten Statement is not Provided

If m e d ical sources tih a t fa ll w itJh in o n e o r more o f tlhe categor ies listed in sect io n 2 23
(d )(5) (C)(i) o f t h e Act d o n o t ·indlu de a writte ,n s t a t em,e n t w itih t h e ir e v id e n c e , w e may
r e f e r tJhem to o u r O IG fo r pot e ntia l furth e r a.ctio n, in dud in g investiga t io n a nd CM P
p u rsu -it

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Information On Excluding Certain Medical Sources ' Evidence
0MB Cont r o l No. XXXX-XXXX
P\ubl ications
Und e r sectio n 223 (d )(5 )(C) (i) o f t h e Soc ia l S e cU1 r ity Act ( Ac t ), we m u st e xcl u d e eviid ence
-fl-tam certain med ica l s•our,ce.s u n less \Y e fi n d \.V e h a v e good cau s,e to con s id e r irt.
S e ctio n s 4 04.1503,b a n d 4 16.903,b of o ur- r e g u l.at io n s, 20 C.F . R.. § ,§ 404 . 1 5 0 3 b a n d
4 1 6 ,903b, s et fort h wh en w e may fi n d good cau se. Tih>ey a lso r eqU1 ire med ica l soU1 rces
tha t fo ll w ith in o n e o f t he categoriies liste d in section 223, (d )(S )(CJ (i) o f the Act to abide
by certain reporbin g r e q u ire m e n -ts.
Fa ilu .-e t o sellf - .-e port m a y r esult in r-efer r a l to our Office o f t he Inspect o r- Ge n e r a l (OIG)
fo,r inv estigatio n a n d l possj b l e pen a lty.

Not e

T he requ i.-em e n t s expla ine d on t h is web p age a nd t h e down loadab le Fac t S h eet
ap p ly to med ical sour-ces t hat f a ll w it h in o n e of th e categon es liste d in s ect io n 223
( d )(5)(C )(i) o f t h e Act. T he o n ly req u iriem e nt that a ls o app lies t o in d iv id u a 'ls
a pp lyingr f o r- o r r-eceiv ing Social Securi ty d is ab il ity ben e f its o r- paymen ts, a n d t h e i rrep r esen ta t ives.., is t h at the y m u s t not r emov e a m e d ical sou rce ' s w r iitte n s ta t ement
(t h e state me n t t h a t in d icates t h e so urce fa lls w itlh in o n e o r mo re o f the cat:e<::iories
listed in sectio n 223( d)(5) ( C)(i) o f t h e Act) befo,re s u bmiitti n g eviide nce firom tha t
medica I source to u s .

Apply O n lin e f o .- D isab ility B e n e fit s
D isability B e n e fit s

A

A

Fa ct Sheset - Ex clus io n of C e rtain
M ed ical S o u rces• Evidence A
o d e l W ritt e n Statem e nt f o r M ed ical
Sou rces F a ll ing under Secti o n 2()8 o r1 53 2 of t he A ct ,..!,..
o d e l Writt e n S t a tem e nt f o r M ed ical
Sou rces F a l Ii ng Und e r- S e ction 1 1 28 o f
th>e Act A
M o d e l W ritt e n Statem e nt f or M ed ical
Sou rces. Fa ll ing Und e r- S e ction 1 1 29 o f
the Act A

Rel at.e d linform ati'on,
D isability P la n n e r
I n f o rm a t ion fo r R e p r e sen t ati v es

> Ba c llc:g ro un d

W h at Y o u N e e d to Kno w A b o u t T h e
O n lin e D is.ability A p plicatio n

>W

hat W e N eed rrom a M edica l Sou rce t hat F a lls W it h in O n e or M o .-e o f t h e
Cat e golf"ies L is t e d in S e ction 223( d D(S )(C) ( i) of the Act

> Wha t

the Stat e ment S h o u ld Incl u de

> Where to P lace the Written S ta teme n t

H e lp in g Som e o n e A pp ly Onlin e

What about SSI?
S upp le rne.n t a l S e cu ri ty I n come (S SI)
p a y s ben e fi ts t o d is.a b led ad u lt s
a n d c h ildre n w iith li m it ed in com e
a n d r eso u rces.

> lfhe W r-itten

Statem e n t M ay No t b e R e mov e d

>W e

M ay R.e<:o n tact a M ed ical Source t hat F a ll's W it h in O n e or M ore o f the
Cate gor ies L is t e d in S e ction 223( d)(S )(C) ( i) of the Act

> What May H appen

I

"

if a W r itte n State m e n t is n o t Provid e d

[ f T h e re a r e Add ition a l Q u estions

If y o u h a ve a d d it iona l q u est io n s , yo u m a y ca ll u s at 1 -,009-772- 121.3 (TTY 1 - 800~
32.5~0778) . Y o u ma y a lso v is it y o w r local Soae:ia l S e c ur- ity o ffice.

L e a .--n M o re ....

~

Mv Social Secu:ritv - Sie n In ex Cre a te

Info rmation fo r Re pre s entative s

I > Ba c llcgimund

W hat Yo u Nee d to Know Ab o u t Th e
O n lin e D is.ab ility A p plicatio n
> W hat W e N eed from a M edical Sou rce t hat Falls W ithin O n e or M ore o f t h e
Cat e gor ies List e d in S e ction 223(dl) (5)(C)(i) o f t h e Act

H e lp in g Som e o n e App ly On lin e

I >W hat t h e Sta,t e ment Sh o u ld Incl u de

What ,a bout SSP.

I > W here to P la c e the Written Statem e n t

S u ppleme n ta l Secu rity In co me (SSI)
pays ben efit s t o d is.a b led adult s
a nd c h ild re n w it h lim it ed income
a n d resources.

>The Written Stateme n t

May Not b e Remov e d

> W ,e M ay Re-contact a M ed ical Source t ha,t Fa lls W ithin O n e or M ore o f the
Cat e gor ies List e d in S e ction 223(d~(5)(C)(i) of t h e Act

>W h a t

Le a r n M o re ...

~

Mv Social Securitv - Sien In

OI'

Crea te

M a y Happen if a W ritte n Stat e m e n t is n o t P rov id e d

I

> [f The r-e a re Addition a l Q u estions

v Priva cy Act Stat e ment - Collection & Use o f Pe rsona l Info rmatio n

S e ctions 208, 221 , 223(d )(5 )(C), 1128, 1129, 1 631{e ), 1 632, a n d 1 633 o f t he Soc ia l
S ecu rity Act (Act) a llo w u s to co lle ct tlh is in fonmatio n. Furnis h ing us t h is info rmati o n is
mandator-y. Failin g to pmvid e t he info rmation may result in rie iienral to o ur Office o f
t he In s p e ctor Gen e ra l fo r f u rth er actio n . W e w ill u se tlhe info r matio n t o det e rm ine if
a n ind ividual is d isabled o .- co n tinu es to be d is ab led u n der- o u .- ru les. W e m a y a ls o
s h are your infor-mation fo,r t h e fo ll o w ing p u r poses, ca I led .-ou tin e u ses: (1) To p .-ivate
m edical a nd v ocatio n a l co n s ulta nts fo r u se in m a kiin g prepara 1Jio n fo r, o r ev a lua t ing
the rres-Ullts of, conSU1 ltat ive m e d ical exam inat io n s o r v oca1iio na l ass,essmen t s wh ic h
t hey 'We re e ngaged to perform by SSA o r Stat e agen cy actin g in acco.-d w itlh s,ectio n s
221 o .- 16.33 o f t h e Act; a nd , (2} To spe c ified bus in ess a n d o the r comm un ity m e m be rs
a nd Fe d e r a l, State , a n d local agencies fo .- verirfication of e lig ib ility fo r ben e fi t s u n der
s ect io n 163l (e ) of tlhe Act . In addi1Jio n, w e m a y s h are tlhis info.-martio n in acco rda nce
wit h tlhe Pr ivacy Act a nd other Fede ra l laws. f ,o r example , wh e re a u tho rized, 'We m a y
u se a nd d iscl'ose tlhis inforrna bo n i·n computer match in g pmgrams, in w h ic h ou r
records are compare <:! w ith oth e r .-ecords t o es t ablis h or ve r ify a pe.-son's eJig ib ility fa.Federa l b.en efit progra ms a n d fo r re paymen t of in cor,rect o r d e linq u e n t debt s u nde r
t h ese p rag rams. A list o f add iitio na I rol.Jlti n e u ses is available in o u.- P riv a cy Act System
of Records otices (SO RN) 60-0089, e n tit led C la ims Fo ld e r Syste m , a nd 60~0320.
,e nt it led Ele c tronic Disability (eDIB ) C la im File . Add ition a l info rma1Jio n and a fu ll list ing
o f a ll o ur SO RNs are av.ail.ab re o n o u.- 'Websit e a t www.ssa.gov/foia/b lu ebo ok.

See Revised Privacy Act
Statement Attached

Fa illure t o s e:lf- r epo rt rna y r esult in r efer = I to our O ffi ce o f t h e Ins p ector G e n.e r-a l (O IG )
fo r inv est ig atio n a n d p oss ib le pen a lty.
Notoe,

The r equ irem e n ts e :xpla ine d o n t h is we bpage a n d t h e do wn load able Fact S h eet
a p p ly t o medical sourc es t h a t f a ll w ith in o n e o f t h e cat egor,ies llste d in section 223
( dl)(S )(C ){i) o f the Act T h e o n ly r equi rem e nt that a lso a pplies t o individ u a ls
a p p lying fo r or receiv in g Social Secu ri ty d isabili ty ben e f its o r pay me nts , and t h e ir
re p r esen tativ es.,. is. t h a t th e y m ust n o t r emov e a med i cal source ' s w r iitte n statem en t

(the s :tatem ent t h a t in d icates t h e s.o u 1rce f a lls with i n o n e or m o re o f th e cate9ories
listed in sectio n 223( dl)(5 ) ( C )(i} o f the Act) b efo re s ubrniittiin g e vide n ce fir-o m tha t

M ode l Writte n S t atem e nt f o r M ed ical
Sou rces F a l Ii ng under Sectio n 208 o r
1 632 of t he A ct .J...
M ode l Writte n Sta t e m e nt f o r M ed ical
Sou rces Fa ll ing Unde r S e ctio n 1.128 o f
tlhe Act _,!...
M od e l Written Sta t e m e nt f o r M ed ical
Sources Fa l Ii ng Unde r S e ctio n 1.1 2 9 o f
tlhe Act _,!...

Rel!ated linfo .-mat:ion

m e dica I source t o u s ..

D is.ab ility P lan n e r

I>

In fo rma t ion f or R e p re sen t ativ es

Ba c k gro .. n d

W h at Y o u Nee d to K no w A b o u t: T h e
O n lin e D is.ab ility A p plicatio n

>W

h a t W e N eed fir-om a M edical Sou rce t hat F a lls W it h in O n e or M o ..-e of t h e
Cat e gor ies L iste d in S e ction 223(d0 (5)(C) ( i) of t h e Act

What about SSI?

li:_ihat the Sta,t e ment S h o u 1ldl Incl u de

~

Help in g S o m e o n e A pp ly O n lin e

S u p p leme rnt a l Secu r ity I n come (SSI)
p ays ben e fi t s t o d isable d ad u lts
a n d c h ild re n wiith lim it ed i nco m e

W here to P la c e the Written S t a te m.e n t

a n d r esou r oes.

> T he Written

S t atem.e n t M a y Not b e Re mov e d

Lear n M o re .. ~

>W

e M a y Re-co ntact a M e d ical S o urc e t hat F a lls W it h in O n e or M ore of t he
Cate gor ies L is t e d in S e ction 223( d ) (5 )(C) ( i) o f t h e Act

>W hat

I>

M a y H a p pen irf a W r itte n State m e n t is n o t P rovid e d

If The ..-e a r e Add itio n a l Quest ions

> P rivac y

I"'

A.ct S t a t e men t - Collectio n & U s e of Perso na l Info r m a t io n

Pa p ervvo r k R edu ct ion Act S t ate m e n t

T h is in fo r m a t io n collec 1Jio n m eets t h e requ ire m e rn t:s of 44 l.l..S.C. § 3507 , a & a m e n ded
b y sectio n 2 o f the P apel"No rk Red u c t,io n Act o f 1.995-. Y o u d o n ot n eed t o c omply
w i t h tJt>ese r e,q u ireme nts u n les.s we d is p la y a v a l1id Offiae of M a n agem e nt a n d Bu d get
con t r o l n u mbe r . W e e stim ate t hat it w ill t a ke a b o u rt 20 m i rn u tes t o read the
i n st:Jru c ti:o n.s., g ,aith e .- t!h e f acts.,. a n d comp le t ,e th e w -rti tten d o o u 1m e ntati o n d e-sc ri b ed

above. Yo u m a y sen d c o mm e nts o n o u.- bi m e e stiinnate abOV1e to: SSA. 6401 Secu rity
Blvd . B a ltim o re. M D 2 1.235-640 1.. Sen d o n ly comm e n t s 1re lati11,g t o o ur t im e estim ate
to thi s add1ress. n o t t h e com p le ·t ,e d \vritte.n d ,ocurne ,n ta t ,io n .
1

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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.