I-2-1-90.Sample - Memorandum for Requesting Missing Medical Evidence

Last Update: 9/28/05 (Transmittal I-2-67)

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Social Security Administration

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Refer to:

 
Office of Hearing and Appeals
5107 Leesburg Pike
Falls Church, VA 22041-3255

MEMORANDUM FOR REQUESTING MISSING MEDICAL EVIDENCE

MEMORANDUM TO :(Name and address of RCALJ)

FROM: (Name and address of HO)

SUBJECT: Request for Additional Assistance in Reconstructing Claim File of (Name and SSN of Claimant)

The reconstructed claim file does not contain all the medical evidence needed to adjudicate the case. Therefore, please obtain, through the Office of the Regional Commissioner (ORC), the evidence indicated below.

[Use paragraphs as needed, and revise as appropriate.]

Please request (a copy) (copies) of the report(s) from the claimant's treating physician(s) covering the period from the date of first treatment to the present date.

Physician's name, medical specialty, and address

Date of first treatment

Please request (a copy) (copies) of the report(s) from the hospital(s) in which the claimant has received treatment.

Name and address of hospital

Date of hospitalization or treatment at clinic

Patient's ID number

(A) consultative examination(s) (was) (were) obtained from the following source(s).

Name and address of hospital

Date of hospitalization or treatment at clinic

Patient's ID number

If the DDS retained (a copy) (copies) of the consultative report(s), please send (a copy) (copies) to us. If (a copy) (copies) (was) (were) not retained, please request a contact with the physician(s) in order to obtain (a copy) (copies) of the report(s).

The claimant is represented by (insert name, address, telephone number).

The representative must be sent copies of any correspondence with the claimant.

To assist you, we have attached original authorization forms for the release of medical evidence and (photocopies of the SSA-3368 and/or SSA-3369) (photocopies of the SSA-3820).

In view of the delay in this case, please have the ORC request priority handling by (insert name and address of the appropriate DDS).

 

Administrative Law Judge

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