Electronic Records Express

www.socialsecurity.gov

Help Desk: 1-866-691-3061

Review/Submit CE Reports

Attach and Upload Files

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CE Report Information:

Prepared By:

Date Prepared:

Patient Information:

Patient Name:

SSN:

DOB:

Request Information:

Provider Name:

Request Type:

Request Date:

Requesting Office:

Request ID:

Disability Examiner:

CE Appointment
Date and Time:

Service Item 1:

Special Instructions:

Files already loaded by your preparer:

Selecting the "Review" link for a file will open a "File Download" box so that you can open the file. If you want to revise a file, save it to your local computer and make your revisions.

Delete the old version of the file. Then upload the saved file using the "Browse" button.

To delete a file from the patient's information, select the checkbox next to the file to be deleted.

Select file(s) to be deleted from this patient's information.

Review

CE Report.tif

Attach and upload files to this response:

A maximum of 8 files can be submitted and all files must total less than 50MB.
File types accepted: .wpd, .doc, .docx, .jpg, .bmp, .mdi, .txt, .xls, .xlsx, .pdf, .rtf, .tiff, .tif

Please do not upload password-protected files because they cannot be processed.

File 1:

File 2:

File 3:

File 4:

File 5:

File 6:

File 7:

Additional Comments:

Comments already here were entered by your preparer.

Comments: (Required)

Characters remaining:

Please read this statement and indicate your agreement by checking the " I have read... " box. When you select "Submit", you will generate an electronic signature and submit your response.

I am certifying under penalty of perjury, that I have been authorized or contracted by the Disability Determination Services to examine the claimant. The report is accurate. By checking the "I have read and agree to the above" checkbox below, I am certifying that I personally conducted, or personally participated in conducting, the consultative examination and have electronically signed the report contained within.

I have read and agree to the above.