I-2-5-14.Obtaining Medical Evidence from a Treating Source or Other Medical Source

Last Update: 9/28/05 (Transmittal I-2-68)

When an ALJ needs additional information about a claimant's impairment(s), he or she will determine if the information may be available from a treating source or other medical source. (See I-2-5-1 for definitions of “treating source” and “medical sources.”) If the ALJ determines that the information may be available from a treating source or other medical source, he or she will attempt to obtain the information by following the procedures in subsections A., B. and C., below.

A. Requesting a Claimant or Representative to Provide Evidence That May be Available from a Treating Source or Other Medical Source

The ALJ or HO staff will request the claimant or representative to identify the claimant's treating source(s) and other medical source(s), and provide all relevant evidence that is available from those sources. To facilitate obtaining the evidence, the ALJ or HO staff should provide the claimant or representative with SSA-827s (2-2003 edition or later) to be signed and dated and presented to the source(s) to be contacted. To access Form SSA-827 in the Document Generation System (DGS) which propagates data from CPMS, go to DGS, click on the “Correspondence” tab then the “Prehearing” tab and then “PH1i827.” The HO staff will then:

  1. Diary the case for 30 days, i.e., add a “Development” action to the case using CPMS,. (See the CPMS Training Manual, Module 7, on the CPMS website for specific instructions on how to establish diaries or use case development in CPMS.)

  2. If the claimant or the representative does not provide the evidence by the diary date, the ALJ or HO staff should contact the claimant or representative to determine why they have not provided it.

  3. Depending upon the reason(s) given, the ALJ may:

    • extend the time for the claimant or representative to provide the evidence (e.g., if the claimant informs the ALJ that a treating source has promised to provide the evidence within a reasonable period);

    • request the evidence from the treating source or other medical source, either directly or through the State agency (See B. and C., below); or

    • obtain the needed information by way of a consultative examination (CE) and/or specific test (e.g., if the claimant informs the ALJ that the requested evidence is not available). (See I-2-5-20, Consultative Examinations and/or Tests.)

The HO is authorized to pay certain physicians and providers for the reasonable cost of providing existing medical evidence that the ALJ needs and asks for (20 CFR §§ 404.1514, 416.914).

B. Requesting Evidence Directly From a Treating Source or Other Medical Source

1. Telephone Requests

When requesting evidence by telephone, the HO staff will, after the telephone call is made:

  1. Send or fax the treating source or other medical source a signed and dated SSA-827 (2-2003 edition or later);

    NOTE:

    The SSA-827 (2-2003 edition or later) authorization is good for 12 months from the date signed. If the authorization has expired, the HO should obtain a new signed and dated SSA-827. To access SSA-827 in the Document Generation System (DGS), go to DGS, click on the “Correspondence” tab, then click on the “Prehearing” tab, then click on the “PH1i827” tab.

  2. Prepare a report of contact (RC) to document the request, and place the RC in the CF. The RC must show:

    • the name, position or title, and telephone number of the HO staff person making the contact;

    • the name, position or title, and telephone number of the person contacted;

    • the date of the contact; and

    • the substance of the telephone conversation, including identification of the evidence requested, the actions to be taken by both the requestor and the source (e.g., the person making the contact promises to provide the source with a signed and dated SSA-827 (2-2003 edition or later) to release the evidence), and the time limits for completion of such actions.

  3. Diary the case for a follow-up contact. (See B.3., Follow-up Procedures, below.)

2. Written Requests

When requesting evidence by letter or by fax, the HO staff will do all three of the following:

  1. Enclose a signed and dated SSA-827 (2-2003 edition or later);

    NOTE:

    The SSA-827 (2-2003 edition or later) authorization is good for 12 months from the date signed. If the authorization has expired, the HO should obtain a new signed and dated SSA-827.

  2. Place a copy of the written request (if a fax, include the cover sheet with proof of transmission) in the CF. (See I-2-5-90 Sample-Medical Development Letter to Treating Source. The HO staff may need to modify this letter when requesting evidence from other sources.)

  3. Diary the case for follow-up (See B.3., Follow-up Procedures, below.).

3. Follow-up Procedures

If a treating source or other medical source does not provide requested evidence within 10 days after the HO's initial telephone or fax request or within 15 days after the HO's initial written request (allowing an additional 5 days for mailing), the HO staff should contact the source (preferably by telephone) to determine the status of the source's action on the request. If the ALJ or HO staff believes that the source may need additional time to respond to the initial request, they may delay the follow-up contact for an additional 10 days.

If the source does not provide the requested evidence within 10 days after the HO's telephone or fax transmission follow-up, or 15 days after the HO's written follow-up, the HO staff should contact the source again to determine the status of the source's action on the request.

If the HO's follow-up contact is made by telephone, the HO staff should prepare an RC to document the CF. The RC must show:

  • the name, position or title, and telephone number of the HO staff person making the follow-up contact;

  • the name, position or title, and telephone number of the person contacted;

  • the date of the follow-up contact; and

  • the substance of the telephone conversation.

If the follow-up is made in writing, the HO staff should place a copy of the written follow-up in the CF. If the follow-up is made by fax, the HO staff should place a copy of the written follow-up, cover sheets and proof of transmission in the CF.

All follow-up dates should be annotated on the “Development” screen in CPMS.

4. Telephone Reports

If a medical source provides information by telephone, the HO staff person receiving the information will:

  1. Prepare an RC which clearly describes the information provided, and shows:

    • the HO staff person's name, position or title, and telephone number;

    • the source's name, position or title, and telephone number; and

    • the date and time of the telephone report.

  2. Send the original RC, along with a postage paid return envelope, to the source for verification, signature, and return to the HO.

  3. Place a copy of the RC in the CF. The RC should become an exhibit to document the ALJ's and HO's attempts to obtain evidence.

5. Payment for Reports

The HO is authorized to pay the same amount for reports that the State agency would pay. See DI 39545.210 - Fee Schedule; DI 11010.545 - Payment for Medical Evidence of Record; and DI 22505.040 - Payment for Medical Evidence of Record.

C. Requesting Evidence From a Treating Source or Other Medical Source Through the State Agency

1. Request Procedures

When requesting evidence from a treating source or other medical source through a State agency, the HO staff should:

  1. Complete and send to the State agency a “Request for DDS Assistance in Obtaining Report(s)” (HA-4488). To access the request, go to the Document Generation System (DGS) and click on the “CE and Evidence Request” tab, then click on the “Request for Medical Evidence Only from State Agency” tab. The HO staff should provide the State agency with:

    • the representative's (if any) name, address and telephone number;

    • a description of the needed evidence and its location;

    • a signed and dated SSA-827 (2-2003 edition or later) to release the evidence;

      NOTE:

      The SSA-827 (2-2003 edition or later) authorization is good for 12 months from the date signed. If the authorization has expired, the HO should obtain a new signed and dated SSA-827.

    • the name and telephone number of a person in the HO that the State agency may contact; and

    • a postage paid return envelope.

  2. Place a copy of the Request for DDS Assistance and other request information in the CF; and

  3. Add a development action in CPMS and diary the case for 30 days.

2. Follow-up Procedures

If the State agency does not provide the requested evidence by the end of the diary period, the HO staff should:

  1. Contact the State agency (preferably by email) to determine the status of the State agency's action on the request;

  2. Prepare an RC for the CF to document the follow-up (if done through written communication or fax, place a copy of the communication and/or fax cover and proof of transmission in the CF); and

  3. Diary the case for the additional time (up to 30 days) that the State agency indicates it needs.

3. Problem With the State Agency's Response

If there is a problem with the State agency's response (e.g., the State agency does not send any evidence, or sends inadequate or incomplete evidence), the HO staff should contact the State agency (preferably by email) and try to resolve the problem. If done through written communication or fax, place a copy of the communication and fax cover sheet and proof of transmission in the CF.

If the HO staff is unable to resolve the problem, and the requested evidence is essential, the HO staff should request assistance from the Regional Office (RO). If done through written communication or fax, place a copy of the communication and/or fax cover and proof of transmission in the CF.

D. Medical Test Data

Medical evidence from treating sources and other medical sources frequently includes reports of medical test results that are not accompanied by the background medical test data (e.g., radiologists' reports of x-rays do not normally include the actual x-ray films, and psychological test reports do not normally include “raw” test data such as answer sheets or drawings). However, background medical test data are required for some pulmonary tests and for electrocardiograms (see 3.00E., 3.00F.1., and 4.00C.1. of the Listing of Impairments). Even if background medical test data are not required, if a report raises a question about the accuracy of the medical test results reported (or other evidence raises such a question), the ALJ may ask the source to submit the background medical test data. Such requests should be rare and, if they occur, interpretation and evaluation of the background medical test data would require a medical expert. (See I-2-5-34 B., When the ALJ Must Obtain ME Opinion.)

NOTE:

Psychological test instruments are available only to qualified testing facilities and personnel. The testing facilities and personnel who use the instruments must purchase them and are not permitted to share them because of copyright restrictions; many tests are too large to copy. Therefore, the ALJ should not request a copy of the test instrument. The ME should be a qualified medical professional who is familiar with the test instrument(s) and can interpret the data submitted for the record. If a report raises a question about the accuracy of the test results reported (or other evidence raises such a question), the ALJ may ask the source to submit the raw test data.