OMB Control No. 0960-0803

Under section 223(d)(5)(C)(i) of the Social Security Act (Act), we must exclude evidence from certain medical sources unless we find we have good cause to consider it.

Sections 404.1503b and 416.903b of our regulations, 20 C.F.R. §§ 404.1503b and 416.903b, set forth when we may find good cause. They also require medical sources that fall within one of the categories listed in section 223(d)(5)(C)(i) of the Act to abide by certain reporting requirements.

Failure to self-report may result in referral to our Office of the Inspector General (OIG) for investigation and possible penalty.

Note

The requirements explained on this webpage and the downloadable Fact Sheet apply to medical sources that fall within one of the categories listed in section 223(d)(5)(C)(i) of the Act.  The only requirement that also applies to individuals applying for or receiving Social Security disability benefits or payments, and their representatives, is that they must not remove a medical source’s written statement (the statement that indicates the source falls within one or more of the categories listed in section 223(d)(5)(C)(i) of the Act) before submitting evidence from that medical source to us.

Background

The Secretary of the Department of Health & Human Services (HHS) or our OIG informs us of medical sources that fall within one of the categories listed in section 223(d)(5)(C)(i) of the Act.

Section 223(d)(5)(C)(i) of the Act mandates that, absent good cause, we cannot consider evidence furnished by a medical source who:

  • was convicted of a felony under sections 208 or 1632 of the Act; or
  • was excluded from participating in any Federal health care program under section 1128 of the Act; or
  • was imposed with a civil monetary penalty(CMP), assessment, or both, for submitting false evidence under section 1129 of the Act.

Sections 404.1503b and 416.903b of our regulations, 20 C.F.R. §§ 404.1503b and 416.903b, define when we may have good cause to consider these sources’ evidence.

Specifically, we may have good cause to consider evidence furnished by these sources when:

  1. the evidence covers treatment that occurred before the source’s felony conviction under section 208 or 1632 of the Act
  2. the evidence covers treatment that occurred when the source was not excluded from participating in any Federal health care program under section 1128 of the Act,
  3. the evidence covers treatment that occurred before the source received a final decision imposing a CMP, assessment, or both, for submitting false evidence, under section 1129 of the Act,
  4. the sole basis for the exclusion of the source’s evidence under section 223(d)(5)(C)(i) of the Act is that the source cannot participate in any Federal health care program under section 1128 of the Act, but the Office of Inspector General of HHS granted a waiver of the section 1128 exclusion, or
  5. the evidence is a laboratory finding(s) about a physical impairment(s) and there is no indication that the finding(s) is unreliable.

What We Need from a Medical Source that Falls Within One or More of the Categories Listed in Section 223(d)(5)(C)(i) of the Act

Each time a medical source that falls within one or more of the categories listed in section 223(d)(5)(C)(i) of the Act submits evidence for a Social Security disability claim, the source must attach a written statement indicating that the source falls within one or more of these categories.

The source must provide this statement with the source’s evidence regardless of whether the source submits the evidence to us directly or through a representative, claimant, or other individual or entity.

We will use this statement to determine whether good cause exists to use the source’s evidence when determining disability.  Thus, it is vitally important that sources submit this statement, and their evidence, to us.

To make it easier for sources to comply with this requirement, we have developed model written statements for each of the categories listed in section 223(d)(5)(C)(i) of the Act.  Although not required, sources that fall within one or more of these categories are encouraged to use these model statements.  The statements may be found under this paragraph and on the right-hand side of this webpage, under the heading, “Publications."

Model Written Statement for Medical Sources Falling Under Section 208 or 1632 of the Act
Model Written Statement for Medical Sources Falling Under Section 1128 of the Act
Model Written Statement for Medical Sources Falling Under Section 1129 of the Act

What the Statement Should Include

Under our rules, medical sources that fall within one or more of the categories listed in section 223(d)(5)(C)(i) of the Act must include their name, title, basis of exclusion, and the following heading:

“WRITTEN STATEMENT REGARDING SECTION 223(d)(5)(C) OF THE SOCIAL SECURITY ACT – DO NOT REMOVE

They must also include the following information, as it applies to their situation:

  • the date of the felony conviction under sections 208 or 1632 of the Act,
  • the reason, effective date, and expected length of the exclusion under section 1128 of the Act, and whether it was waived by HHS’ Office of Inspector General, and
  • the date of the CMP, assessment, or both, under section 1129 of the Act.

Where to Place the Written Statement

Medical sources that fall within one or more of the categories listed in section 223(d)(5)(C)(i) of  the Act should place their written statement before the first page (but after any barcode page) of evidence they submit as part of a Social Security disability claim.

The Written Statement May Not be Removed

No individual or entity may remove the written statement before submitting the evidence to us. 

We May Recontact a Medical Source that Falls Within One or More of the Categories Listed in Section 223(d)(5)(C)(i) of the Act

We may ask medical sources that fall within one or more of the categories listed in section 223(d)(5)(C)(i) of the Act for more information concerning their written statement or for clarification of information that they already provided.

What May Happen if a Written Statement is not Provided

If medical sources that fall within one or more of the categories listed in section 223(d)(5)(C)(i) of the Act do not include a written statement with their evidence, we may refer them to our OIG for potential further action, including investigation and CMP pursuit.

If There are Additional Questions

If you have additional questions, you may call us at 1-800-772-1213 (TTY 1-800-325-0778).  You may also visit your local Social Security office

Privacy Act Statement – Collection & Use of Personal Information

Sections 208, 221, 223(d)(5)(C), 1128, 1129, 1631(e), 1632, and 1633 of the Social Security Act (Act) 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: (1) 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, (2) 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) 60-0089, entitled Claims Folder System, and 60-0320, entitled Electronic Disability (eDIB) Claim File. Additional information and a full listing of all our SORNs are available on our website at www.ssa.gov/foia/bluebook.

Paperwork Reduction Act Statement

This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to comply with these requirements unless we display a valid Office of Management and Budget control number. We estimate that it will take about 20 minutes to read the instructions, gather the facts, and complete the written documentation described above. You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed written documentation.

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