Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)

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DCPS ELZA GLEICHNER
5170 WALKER OVERPASS
ERNESTINEFURT NM 86456

CONFIDENTIALITY NOTICE: The accompanying material contains sensitive information. This information may be privileged and
confidential, and intended for the use of the recipient named in this correspondence. If you have received this information in error,
please contact us immediately.

DISABILITY DETERMINATIONS SERVICE
SSA
S09 Delaware DDS
SUITE 300
NEW CASTLE, DE 19720-1000
TEL: (555) 555-5555
Date: Mar 8, 2022
Case ID: 21665
DCPS ELZA GLEICHNER
5170 WALKER OVERPASS
ERNESTINEFURT NM 86456

T

We are the office that makes disability decisions for the Social Security Administration. We are writing about your disability
claim because we need more information about your condition, daily activities, or work history.

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What You Need To Do

Complete these form(s) with black or blue ink. We realize that some of the questions may not seem relevant to the case,
but please answer all of the questions to the best of your ability.
Return the completed form(s) by March 18, 2022. If you do not return the form(s), we may decide the case based on the
information we already have on file. This means that we could find that you are not disabled based on our rules or that your
disability has ended if you are already getting benefits.
How To Return The Form(s)

You may use the enclosed return envelope or fax your completed form(s) to us at (123) 456-7945. Please note the return
address may be to a scanning center who works with us. The completed form(s) must include the barcode page on top of
the form(s).
If You Have Any Questions

If you have any questions or wish to provide more information, please call us at the number(s) shown below Monday - Friday
between 11:30 am and 7:30 pm. When you call or leave a message, please provide the Case ID: 21665, your name, and a call
back number.
Thank you for your help.

S. Schmidt
(301) 555-1212
(987) 654-3210 (FAX)

cc: Alternate1 M. ContactLastname1, Sr
Enclosure(s):
Seizure Questionnaire
Privacy Act and Paper Reduction Act Statement
Return Envelope

21665/ Assigned 2723 L556/ DCPS / / OMB No. 0960-0555 / 98022152

Form Approved
OMB No. 0960-0555
Date: Mar 8, 2022
Case ID: 21665
Claimant Name: DCPS Elza Gleichner

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SEIZURE QUESTIONNAIRE

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PLEASE COMPLETE AND RETURN BY MARCH 18, 2022

If you need more space, please attach additional page(s).
1) Do you have seizures?
If yes:

Yes

No

a) When was your first seizure?

b) When did you have your last seizure?

c) Do your seizures usually occur during the day, during the night, or both? Please explain.

d) How long do the seizure(s) last?
e) How often do seizures occur?

f) List the approximate date(s) of seizure(s) in the last 12 months.

g) Describe what happens before, during, and after you have a seizure and how long until you can resume normal activity.

21665/ Assigned 2723 L556/ DCPS / DCM12506 / OMB No. 0960-0555 / 98022152

2) Describe event(s) that cause your seizure(s).

3) List current seizure medication(s).
DATE
STARTED

IF PRESCRIBED, NAME OF HEALTH CARE
PROFESSIONAL

SIDE
EFFECT(S)

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MEDICATION, DOSAGE, AND
FREQUENCY

4) Have you visited an emergency room for seizures? If so, when and where?

5) If you have seen any health care professionals for your seizures since you filed your claim, complete the chart below.
NAME OF HEALTH CARE
PROFESSIONAL

ADDRESS AND PHONE
NUMBER

DATE OF LAST VISIT AND NEXT SCHEDULED
APPOINTMENT (IF ANY)

21665/ Assigned 2723 L556/ DCPS / DCM12506 / OMB No. 0960-0555 / 98022152

6) Provide the name, address, and phone number of any health care professionals and other individuals (including non-family
members) who have witnessed your seizure(s).
ADDRESS AND PHONE NUMBER

PHONE NUMBER

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WITNESS NAME

Name of person completing this form (Please print)

Date

Phone

Address

City

State

21665/ Assigned 2723 L556/ DCPS / DCM12506 / OMB No. 0960-0555 / 98022152

ZIP

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d) and 1631(d) and (e) of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from
making an accurate and timely decision on any claim filed.
We will use the information to make a determination regarding your ability to perform work-related activities. 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 examination or vocational assessments which they were engaged to perform by SSA or a State agency acting in
accord with sections 221 or 1633 of the Act; and

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2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration
(SSA) in the efficient administration of its programs. We will disclose information under this routine use only in
situations in which SSA may enter into a contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records.
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) 60-0044, entitled National
Disability Determination Services File System and 60-0089, entitled Claims Folders Systems. Additional information and a
full listing of all our SORNs are available on our website at www.socialsecurity.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 answer these questions unless we display
a valid Office of Management and Budget (OMB) control number. We estimate that it will take about 20 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.

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ALTERNATE1 MIDDLENAME1 CONTACTLASTNAME1 SR
3792 AUFDERHAR GROVE
STREET ADDRESS LINE 2
STREET ADDRESS LINE 3
STREET ADDRESS LINE 4
JANIEMOUTH IA 27903

CONFIDENTIALITY NOTICE: The accompanying material contains sensitive information. This information may be privileged and
confidential, and intended for the use of the recipient named in this correspondence. If you have received this information in error,
please contact us immediately.

DISABILITY DETERMINATIONS SERVICE
SSA
S09 Delaware DDS
SUITE 300
NEW CASTLE, DE 19720-1000
TEL: (555) 555-5555
Date: Mar 8, 2022
Case ID: 21665
DCPS ELZA GLEICHNER
5170 WALKER OVERPASS
ERNESTINEFURT NM 86456

T

We are the office that makes disability decisions for the Social Security Administration. We are writing about your disability
claim because we need more information about your condition, daily activities, or work history.

D
EN E
M
V O
IR
O
N
M
EN

What You Need To Do

Complete these form(s) with black or blue ink. We realize that some of the questions may not seem relevant to the case,
but please answer all of the questions to the best of your ability.
Return the completed form(s) by March 18, 2022. If you do not return the form(s), we may decide the case based on the
information we already have on file. This means that we could find that you are not disabled based on our rules or that your
disability has ended if you are already getting benefits.
How To Return The Form(s)

You may use the enclosed return envelope or fax your completed form(s) to us at (123) 456-7945. Please note the return
address may be to a scanning center who works with us. The completed form(s) must include the barcode page on top of
the form(s).
If You Have Any Questions

If you have any questions or wish to provide more information, please call us at the number(s) shown below Monday - Friday
between 11:30 am and 7:30 pm. When you call or leave a message, please provide the Case ID: 21665, your name, and a call
back number.
Thank you for your help.

S. Schmidt
(301) 555-1212
(987) 654-3210 (FAX)

cc: Alternate1 M. ContactLastname1, Sr
Enclosure(s):
Seizure Questionnaire
Privacy Act and Paper Reduction Act Statement
Return Envelope

21665/ Assigned 2723 L556/ DCPS / / OMB No. 0960-0555 / 98022152

Form Approved
OMB No. 0960-0555
Date: Mar 8, 2022
Case ID: 21665
Claimant Name: DCPS Elza Gleichner

D
EN E
V MO
IR
O
N
M
EN

SEIZURE QUESTIONNAIRE

T

PLEASE COMPLETE AND RETURN BY MARCH 18, 2022

If you need more space, please attach additional page(s).
1) Do you have seizures?
If yes:

Yes

No

a) When was your first seizure?

b) When did you have your last seizure?

c) Do your seizures usually occur during the day, during the night, or both? Please explain.

d) How long do the seizure(s) last?
e) How often do seizures occur?

f) List the approximate date(s) of seizure(s) in the last 12 months.

g) Describe what happens before, during, and after you have a seizure and how long until you can resume normal activity.

21665/ Assigned 2723 L556/ DCPS / DCM12506 / OMB No. 0960-0555 / 98022152

2) Describe event(s) that cause your seizure(s).

3) List current seizure medication(s).
DATE
STARTED

IF PRESCRIBED, NAME OF HEALTH CARE
PROFESSIONAL

SIDE
EFFECT(S)

D
EN E
V MO
IR
O
N
M
EN

T

MEDICATION, DOSAGE, AND
FREQUENCY

4) Have you visited an emergency room for seizures? If so, when and where?

5) If you have seen any health care professionals for your seizures since you filed your claim, complete the chart below.
NAME OF HEALTH CARE
PROFESSIONAL

ADDRESS AND PHONE
NUMBER

DATE OF LAST VISIT AND NEXT SCHEDULED
APPOINTMENT (IF ANY)

21665/ Assigned 2723 L556/ DCPS / DCM12506 / OMB No. 0960-0555 / 98022152

6) Provide the name, address, and phone number of any health care professionals and other individuals (including non-family
members) who have witnessed your seizure(s).
ADDRESS AND PHONE NUMBER

PHONE NUMBER

D
EN E
V MO
IR
O
N
M
EN

T

WITNESS NAME

Name of person completing this form (Please print)

Date

Phone

Address

City

State

21665/ Assigned 2723 L556/ DCPS / DCM12506 / OMB No. 0960-0555 / 98022152

ZIP

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d) and 1631(d) and (e) of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from
making an accurate and timely decision on any claim filed.
We will use the information to make a determination regarding your ability to perform work-related activities. 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 examination or vocational assessments which they were engaged to perform by SSA or a State agency acting in
accord with sections 221 or 1633 of the Act; and

D
EN E
M
V O
IR
O
N
M
EN

T

2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration
(SSA) in the efficient administration of its programs. We will disclose information under this routine use only in
situations in which SSA may enter into a contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records.
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) 60-0044, entitled National
Disability Determination Services File System and 60-0089, entitled Claims Folders Systems. Additional information and a
full listing of all our SORNs are available on our website at www.socialsecurity.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 answer these questions unless we display
a valid Office of Management and Budget (OMB) control number. We estimate that it will take about 20 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.