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SOCIAL SECURITY ADMINISTRATION _____________________________________________________________ | |
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Refer to: TAHB [SSN] [XSSN] |
Office of Hearings and Appeals 5107 Leesburg Pike Falls Church, VA 22041-3255] | |
Last Update: 9/1/05 (Transmittal II-6-13)
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SOCIAL SECURITY ADMINISTRATION _____________________________________________________________ | |
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Refer to: TAHB [SSN] [XSSN] |
Office of Hearings and Appeals 5107 Leesburg Pike Falls Church, VA 22041-3255] | |
[First Name, Middle Initial and Last
Name]
[Address]
[City, State
Zip]
Dear [Dr./Mr./Ms. [Last Name]]:
Re: [Claimant's Name and Address]
This is about the report we received from you dated [insert date]. Under our rules, all medical reports must be personally signed by the individual who performed the examination. Because the enclosed report was not properly signed, we are returning it to you.
Please review the report and make any required changes. Please sign the report and return it no later than 10 days from the date of this letter.
You may return the report using the enclosed self-addressed mailing label or you may FAX it to [FAX #], Attn: Branch [#]. Please include the claimant's Social Security Number shown above on all correspondence.
If You Have Any Questions
If you have any questions, you may call or write the Appeals Council. Our telephone number and address are shown at the top of this letter. If you do call, please have this notice with you.
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[Name] [Hearings and Appeals Analyst] OR [Branch Chief] |
Enclosures:
[Medical report dated [insert
date]]
Self-addressed mailing label
cc:
DDS, [insert city and state of
DDS]
[Claimant's Name]
[Address]
[City, State Zip]
[If there is a representative,
insert]:
[Representative's
Name]
[Address]
[City, State Zip]