Electronic Records Express

www.socialsecurity.gov

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Review/Submit CE Reports

Destination and Request Information

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CE Report Information:

Prepared By:

Date Prepared:

Reviewing Provider:

Patient Information:
Enter the Patient's Information.

First Name:

Middle Name:

Last Name:

DOB:

Enter 3 character site code or select state and destination:

Site code: OR State:

Destination:

Enter the following information from the request letter or barcode:

SSN:

RQID (Request ID):

RF (Routing Field):

- P D or blank No RF or No Barcode

DR:

- F S No DR or No Barcode

CS:

(enter only if applicable)