I-4-3-111. Exhibit - Request for Medical Comments

[ ] Program Review Branch

[ ] Request for Review

[ ] New Court Case

[ ] Civil Actions Branch

[ ] Comprehensive Review

[ ] Court Remand

Claimant

Analyst

Date

SSN

Reviewer

Date

DOB

[ ] Initial Entitlement

[ ] Cessation

[ ] New Referral

[ ] Prior Referral

[ ] Title II

[ ] Title XVI

AOD (Where applicable)

DLI (Where applicable)

Period at issue

Evaluation needed on Body System(s). Check all that apply.

[ ] Skin

[ ] EENT

[ ] MS

[ ] Psych

[ ] Endo

[ ] CV

[ ] GU

[ ] Malig

[ ] Resp

[ ] GI

[ ] Neuro

[ ] Hemic & Lymph

Request for medical comments where a consultative examination may not be needed.

See page 2.

[ ] We plan to recommend that the Appeals Council obtain additional medical evidence. We believe that one CE with tests/studies is needed for the body system(s) we checked above. If you agree, indicate below the special tests or studies required or if multiple examinations are necessary. Under “Pertinent Factors” on the next page, we have explained why CE(s) may be needed and cited relevant exhibits.

Also, indicate below if the claimant should bring the following to the exam.

[ ] Sample(s) of currently prescribed medicine

[ ] Glasses or Contact Lenses

[ ] Artificial limb or other prosthetic devices

[ ] Back Brace

[ ] Hearing Aid

[ ] Other (Explain)

Any additional remarks:

Medical Staff

Date

Medical Testimony At Hearing:

[ ] None

[ ] Medical Expert

[ ] See notes, left side of AF

[ ] See p. ___ of transcript

[ ] Other (Claimant's physician, CE)

[ ] See notes, left side of AF

[ ] See p. ___ of transcript