Sample CE Forms

CE Credentialing
StateLetterhead]
[Standard Header]

[Addressee information]
We are the office that makes disability decisions for the Social Security Administration. We
have been informed that you may be interested in performing consultative examinations for our
[bureau/agency].
To be included on our Panel of Consultants, we must receive and review your curriculum vitae
which should include the following:
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Medical school and date of graduation
Place and dates of residency training
Social Security Number
State Medical License Number or Copy of State Medical License Certificate
Board Certification and specialty
Hospital affiliations
Department name and address of any [state agency] personnel payroll(s) you are
on at this time
Individual Tax Identification Number (Please complete attached Tax
Identification Number Form)
Corporate or group Tax Identification Number if you use one for a group practice
Place and date of birth
ECFMG # if foreign medical graduate

Enclosed with this letter is information regarding the disclosure of medical information under the
Federal Privacy Act of 1974. Our [bureau/agency] is currently required to obtain a written
acknowledgement of the responsibility of confidentiality from all persons who perform
consultative examinations. You will also find the License/Credentials Certification statement for
your signature and a current fee schedule.
Please forward to us your curriculum vitae and your signed Medical Disclosure
Acknowledgement form. Your application will then be given every consideration by the
Credential Committee.

Special Instructions:

[Standard Footer]

[special instructions]

If you have any questions, please contact us at the number(s) shown below from
[LocalOfficeHours]. When you call or leave a message, please provide your name and a call
back number.
Thank you.
[Standard Signature block]

Enclosure(s):
[attachments]
File Type
application/pdf
File Title
 Sample CE Forms
Author
889123
File Modified
2017-06-13
File Created
2014-06-12