Last Update: 9/28/05 (Transmittal I-2-67)
The hearing office (HO) staff will select exhibits and prepare an exhibit list for the ALJ's approval. The criterion for selecting a document as an exhibit is whether the document is material to the issues in the case. See I-2-1-15 E, Examples of Documents Identified As Proposed Exhibits.
NOTE:
The documents selected by the HO staff will be considered “proposed exhibits” until the ALJ formally admits them into evidence.
Miscellaneous working papers, transmittal forms or route slips, intra-departmental communications, and documents pertaining solely to an auxiliary claimant who is not a party to the hearing.
Documents classified as “Confidential” by the source (Department of Veterans Affairs, local government unit, etc.), when efforts to obtain release of the restrictions have been unsuccessful. Similarly, any determinations, analyses, or reports, which refer to the confidential document or contain excerpts from it, may not be admitted as evidence.
The Modular Disability Folder (MDF) was created to deal with the increased complexity of the disability program and to promote uniform folder assembly for all components within SSA that process disability claims. With the implementation of the MDF, Hearing Office (HO) staff will no longer remove documents from the claim file (CF) in order to create a separate exhibit file. With the exception of I-2-1-15 C(2), all CF material will be housed in a specific part of the MDF.
The MDF is designed to facilitate the location of related materials (e.g., all medical records are filed together), to encourage the users to discard extraneous or duplicate material, and to provide for uniform folder assembly by all users.
The MDF requires that all documentation be housed in a specific section (or part). The parts are named as follows:
|
Part A - |
Payment Documents/Decisions - Yellow (Front) |
|
Part B - |
Jurisdictional Documents/Notices - Red |
|
Part C* - |
Current Development/Temporary - Green |
|
Part D - |
Non-Disability Development - Orange |
|
Part E - |
Disability Related Development and Documentation -Blue |
|
Part F - |
Medical Records -Yellow (Back) |
*No exhibits are to be housed in this section, since it is for working papers only.
In concurrent Title II/Title XVI claims or multiple claims under Title II, a two part folder will house the additional claims. The Title II claim will usually be in the MDF.
These two-part folders will be named as follows:
|
Part |
Description |
|
SSI |
Supplemental Security Income |
|
DWB |
Disabled Widow's/Widower's Benefits |
|
CDB |
Child's Disability Benefits |
When the HO receives the claim file, all documentation will be housed in its designated part of the MDF, arranged in the specified order.
NOTE:
Prior to the hearing level, Field Office (FO) and Disability Determination Services (DDS) employees are responsible for filing the documentation relative to all levels of claims processing.
In concurrent and multiple filing cases, the Title II portion will be housed in the MDF. Any other claim will be in the standard two-part claim file and attached to the MDF. All material in these folders will remain in these folders and will not be reassembled.
The MDF contains six sections, and each is color-coded and labeled to facilitate filing. The divider tabs list examples of the documents to be filed in each section. (The lists are not all-inclusive.) You will need to exercise judgment as to where some documents not listed should be filed.
Materials in three of the six sections (i.e., Yellow (Front), Red and Blue) are to be filed in chronological order (i.e., oldest document on the bottom and newest on the top). In most cases chronological filing will occur naturally as documents are filed as received.
Materials in the Green section can be filed in any order since these materials will eventually be purged or moved to another section.
Materials in the Orange and Yellow (Back) sections are to be filed according to instructions in DI 70005.005.B.4. and DI 70005.005.B.6.
NOTE:
Some sections of the MDF will have relatively few documents while others may be quite full.
This section serves primarily to house documents pertaining to entitlement and payment of benefits. Examples of documents to be filed here are the SSA-831, SSA-101, ALJ decision, etc. Most documents to be filed here have holes for top filing.
This section documents the current level of adjudication by containing notices and appeal requests. Appointment of Representative documents (SSA-1696, etc.) are also filed here.
The purpose of this section is to encourage users to discard extraneous material as actions are taken. In essence, this is the “work in progress” section. For example, a letter requesting medical records from a treating source would be filed in the Green section. When the records are received, the request letter would then be discarded. If the records are not received by the time the disability determination is made, the request letter will be moved to the Yellow/Back section (Medical Records) to document the attempt.
NOTE:
Each user is responsible for determining what is pertinent and what can be discarded. Guidelines for determining what is extraneous are provided in DI 22520.001 for DDSs, GN 01050.150B. and GN 01050.240 - GN 01050.245 for Title II claims, and GN 00301.295 - GN 00301.300 for all claims.
NOTE:
When the folder is sent to another location for processing or filing, the Green section should normally be empty.
This section houses claims applications, evidence, earnings records, essential queries, documentation of earnings, non-disability postentitlement development, congressional inquiries/responses, etc. See GN 01050.190A.1. - GN 01050.190A.8. for Title II assembly order that is applicable for the MDF or the two part brown folder.
NOTE:
Requests for appeal are filed in the Jurisdictional Documents/Notices section.
This section is for disability questionnaires such as the SSA-3368, SSA-3441, and SSA-820/821s. It is also for disability related correspondence and forms such as SSA-827s.
The materials in this section will be filed in chronological order, except that the HO will place all usable SSA-827 on the top.
All medical evidence will be filed in this section. This includes hospital records, laboratory reports, physician's records, outpatient notes, RFC forms, comments and analyses of program physicians and psychologists, etc. Keep cover letters together with the accompanying records, as they help identify the source. DDSs will place their worksheets and development records on top of this section.
NOTE:
An Office of Inspector General (OIG) Cooperative Disability Investigation (CDI) Report of Investigation (ROI) should be filed on top of all medical material.
The following are examples of documents that are usually identified as proposed exhibits:
(Filed in chronological order - most recent on top).
SSA-831 (Disability Determination and Transmittal).
NOTE:
Any PRTF or RFCA forms (previously attached to the SSA-831) are no longer considered attachments. These are considered medical/evidentiary documents and will be housed in Part F (Medical Records).
SSA-832 and SSA-833 (Cessation or Continuance of Disability/Blindness Determination for Title XVI and Title II).
Previous decisions or dismissals or revised determinations rendered by an ALJ.
(Filed in chronological order - most recent on top).
SSA/SSI Notice of Disability/Blindness (Denial/Award).
SSA-561 (Request for Reconsideration).
Notice of Reconsideration (Denial/Award).
HA-501 (Request for Hearing by ALJ).
The initial determination form and the notice of initial determination.
In cessation cases, the notice of planned action, the cessation determination form and the initial termination notice.
In overpayment cases, the initial notice of overpayment.
The request for reconsideration in those states which are not prototype states. (See I-2-4-98, Exhibit – Prototype States and Case Processing.)
The reconsideration determination and notice of the reconsideration determination in those states which are not prototype states. (See I-2-4-98, Exhibit – Prototype States and Case Processing.)
In Appeals Council remand cases (including remands following claimants' request for review and remands based on court orders), the Appeals Council remand order.
This section is reserved for working papers only. There should be no material which would be identified as an exhibit in this section.
The application (paper or computer printouts), and any written statement or record of oral inquiry indicating an intent to claim benefits which serves as a protective filing.
Birth Certificate or other proof of age.
Earnings records and proof of any non-posted wages or self-employment income.
Workers' Compensation and Department of Veterans Affairs or other federal agency award information.
Evidence of death and relationship (in auxiliary and survivor cases).
Verification of any work activity engaged in by the claimant after the alleged onset date.
Pertinent statements or reports of contact (not disability related).
(Filed in chronological order - most recent on top).
SSA-3368 (Disability Report - Adult).
SSA-3369 (Work History Report).
SSA-3441 (Disability Report-Appeal).
SSA-3820 (Disability Report-Child).
SSA-454 (Report of Continuing Disability).
SSA-455 (Disability Update Report).
School Records (Teacher Evaluations Only).
Supplemental Questionnaires (Activities of Daily Living Forms).
Unsuccessful Attempts to Obtain Necessary Disability Documentation.
Any Other Documentation Relating to Development of Disability.
State Vocational Reports.
SSA-821 (Work Activity Report- Employee).
SSA-820 (Work Activity Report-Self Employed).
DDS worksheet.
Electronic Disability Collect System (EDCS) Routing Form.
SSA-3341 (Disability Report—Appeal).
NOTE:
Form HA-4486, which was supplanted by Form SSA-3341, may be seen in pending cases for some time.
Pain Questionnaires.
Seizure Questionnaires.
Pertinent reports of contact.
A written summary of the case, or written statements about the facts and law material to the case, submitted by the claimant or the claimant's representative.
Letters from employers or other individuals describing the claimant's impairments and limitations.
(Filed in treatment-date order).
CDI Report of Investigation (when in file)-must be filed on top.
Treatment Records.
Hospital Records.
Laboratory/Imaging Reports.
Outpatient Notes.
Clinic Notes.
Physician's Records and Reports.
Cover Letters from treatment source if Medical Evidence not otherwise identified.
X Ray Findings.
Examination Reports.
Medical opinions, analyses, and residual functional capacity assessments by physicians or mental health professionals.
School Records (Multi-Discipline Evaluations and/or Psychologist Evaluations).
Professional Qualifications (PQs) of all health care professionals whose reports, analyses, assessments, or judgments are being entered into the record of exhibits. (See I-2-1-30, Professional Qualifications of Health Care Professionals.)
SSA-5002 (Report of Contact) - Disability Related.
Letters of Unsuccessful attempts to obtain M/E.
SSA-4734 (Residual Functional Capacity Assessment) (DDS Physician).
SSA-2506 (Psychiatric Review Technique - PRT Form) (DDS Physician).
Capability Opinions - Completed by the DDS Physician.
Medical records, filed in the Yellow (Back), should be filed in treatment-date order, according to user preference, at the ALJ level.
Treatment-date order means that medical records are filed according to the dates of treatment, with the record of oldest treatment on the bottom and the most recent on top. This does not mean, however, that every single piece of medical evidence will be filed as a separate document. For example:
Hospital records pertaining to one period of hospitalization should be kept together. This may include an admission summary, laboratory reports, progress notes, surgical procedures and a discharge summary.
If a hospital provides records for multiple periods of hospitalization, the records for each stay should be treated as separate records and interfiled with other records in treatment-date order.
If a claimant has been seen only as an outpatient at a hospital (such as in a clinic or emergency room), the records should be kept together with the oldest on bottom and the newest on top.
Treating physician records that include laboratory reports or x-rays should all be filed as one document.
Multiple records from one physician that cover a period of time should be kept together with the oldest treatment date on the bottom.
NOTE:
The most recent date of treatment in the topmost record of each set is the controlling date for interfiling records. (See EXAMPLE.)
On Bottom - Hospital records from County Hospital for a stay 7/24/91 through 7/31/91.
Medical reports from Dr. Kildare with attached laboratory reports that cover a period from 7/2/91 through 8/1/92.
Hospital records with EKG that covers a hospital stay at County Hospital from 9/15/92 through 9/19/92.
VA Hospital outpatient records covering 7/29/92 through 10/14/93.
On Top - A consultative examination performed by Dr. Casey on 8/9/94.
For maximum efficiency and productivity, it is vital that duplicate or unnecessary material not be filed in the folder. If unsure whether material needs to be retained, file it in the Current Development/Temporary Section (Green), Part C.
When all actions are complete, purge the Green Part C section by either discarding the material or filing it in another section for documentation purposes. Because duplicate medical records are the most common source of extraneous material, each incoming medical record should be checked against existing records to determine if it is already wholly or partially in file. If so, the duplicate material should be discarded, keeping the most legible copy. Ensure that the copy being discarded does not contain additional entries or annotations.
If an MDF becomes full, any additional medical records will be filed in a brown two-part folder. That folder will be annotated with the NH's name and SSN and be stapled directly to the back of the MDF. Concurrent claims (SSI/DWB/CDB) should be stapled to the back of the overflow folder.
The most recent medical records will be placed in the two-part folder to eliminate excessive re-filing of material.
The following exhibit will be used when the MDF is full and additional medical records are going to be filed in an attached brown folder. Place this flag on top of the Medical Records section of the MDF and annotate below the period of time covered by the records in that section.
DO NOT FILE ANY MORE RECORDS HERE
More Recent Medical Records are in a Brown Folder Attached to this Folder
This Section is full – file any additional medical records in a two-part brown folder and attach it to the back of this folder. Continue to file the most recent records on top in the brown folder.
This section contains medical records for the period __(date)______ through ____(date) .
The following is a partial numerical list of standardized Title II and Title XVI claim file forms and the section of the MDF in which they are filed.
|
An asterisk (*) identifies Title XVI forms. If you are working on a Title XVI only claim, these forms will be filed in the MDF. If you are working on a concurrent claim, these forms will remain in a separate brown folder housing the Title XVI non-medical material. |
|
Form Number |
Document Name |
Color |
|---|---|---|
|
SSA-3 |
Marriage Certification |
Orange |
|
HA-L8 |
Letter to Vocational Expert Requesting Attendance at a Hearing |
Red |
|
HA-L9 |
Letter to Medical Expert Requesting Attendance at a Hearing |
Red |
|
SSA-11 |
Request to Be Selected As Payee |
Orange |
|
SSA-16 |
Application for Disability Insurance Benefits |
Orange |
|
HA-L34 |
Notice of Change in the Time or Place of Hearing |
Red |
|
SSA-101 |
Determination of Award |
Yellow (Front) |
|
SSA-L106 |
Letter to Custodian of School Records (Discard upon receipt of requested evidence; otherwise, move to Blue section.) |
Green |
|
SSA-392 |
Medical Consultant's Review of Residual Functional Capacity Assessment (Physical/Mental) |
Yellow (Back) |
|
SSA-416 |
Office of Disability, Office of Medical Evaluation (Medical Note) |
Yellow (Back) |
|
SSA-450SI* |
SSI Data Input and Determination |
Orange |
|
SSA-454 |
Report of Continuing Disability Interview |
Blue |
|
SSA-455 |
Disability Update Report |
Blue |
|
HA-501 |
Request for Hearing by ALJ |
Red |
|
HA-504 |
Acknowledgment of Notice of Hearing |
Red |
|
HA-520 |
Request for Review of Hearing Decision |
Red |
|
HA-526 |
Professional Qualifications-DDS Physician |
Yellow (Back) |
|
HA-526 |
Professional Qualifications-Treating Physician |
Yellow (Back) |
|
SSA-538 |
Childhood Disability Evaluation Form |
Yellow (Back) |
|
SSA-546 |
Workers' Compensation/Public Disability Benefit Questionnaire |
Orange |
|
SSA-561 |
Request for Reconsideration |
Red |
|
SSA-632 |
Request for Waiver of Overpayment Recovery or Change in the Repayment Rate |
Orange |
|
SSA-633 |
Agreement to Refund Overpayment |
Orange |
|
SSA-635 |
Waiver Determination |
Yellow (Front) |
|
HA-649, 652, 653, 655, 656, 657, 658, 659, 660, 661, 662 |
Requests for Consultative Examination and Evaluation (Discard upon receipt of all requested evidence; otherwise, move to the Yellow (Back) section.) |
Green |
|
SSA-704 |
Certification of Contents of Documents or Records Certification (stays with the document being certified in its respective section) |
|
|
SSA-765 |
Response to Notice of Revised Determination |
Red |
|
SSA-769 |
Request for Change in Time/Place of Disability Hearing |
Red |
|
SSA-770 |
Notice Regarding Substitution of Party upon Death of Claimant-Reconsideration of Disability Cessation |
Red |
|
SSA-773 |
Waiver of Right to Appear–Disability Hearing |
Red |
|
SSA-789 |
Request for Reconsideration-Disability Cessation |
Red |
|
SSA-795 |
Statement of Claimant or Other Person (Non-Disability) |
Orange |
|
SSA-795 |
Statement of Waiver of Advance Notice of Disability Hearing |
Red |
|
SSA-795 |
Statement of Claimant or Other Person (Disability Related) |
Blue |
|
SSA-820 |
Work Activity Report (Self-Employed Person) |
Blue |
|
SSA-821 |
Work Activity Report (Employee) |
Blue |
|
SSA-824 |
Report on Individual With Mental Impairment |
Yellow (Back) |
|
SSA-827 |
Authorization for Source to Release Medical Information to SSA (Not dated or dated within the last 6 months. It is imperative that expired SSA-827's be purged from the file.) |
Blue |
|
SSA-828 |
Request for Medical Information from Records of Veterans' Administration (If Part III-A contains evidence related to a medical condition or if Part III-B is completed, file in Yellow (Back) |
Blue |
|
SSA-829 |
Request for Medical Information from Military Facilities or Record Center |
Blue |
|
SSA-831 |
Disability Determination and Transmittal (with rationale) |
Yellow (Front) |
|
SSA-832 |
Cessation or Continuance of Disability or Blindness Determination and Transmittal (with rationale) Title XVI |
Yellow (Front) |
|
SSA-833 |
Cessation or Continuance of Disability or Blindness Determination and Transmittal (with rationale) Title II NOTE: A professional qualification (PQ) for a DDS physician should be filed in the medical records section Yellow (Back) |
Yellow (Front) |
|
SSA-847 |
SSA Request for Case Action |
Blue |
|
SSA-882 |
Report of Field Review of Continuing Disability |
Blue |
|
SSA-887 |
Summary of Evidence |
Blue |
|
SSA-888 |
Reconsideration/Disability Hearing Process |
Red |
|
SSA-899 |
Continuing Disability Review (CDR) |
Blue |
|
SSA-L991* |
Supplemental Security Income Information |
Orange |
|
SSA-1128 |
Representative Involved (Staple to Bottom Right Corner–Front of File) |
|
|
SSA-1129 |
Attorney Fee Case-Past Due Benefit Summary |
Yellow (Front) |
|
SSA-1203 |
Determination of Benefits Payable After Offset |
Yellow (Front) |
|
SSA-1204 |
Disability Hearing Officer's Report of Disability Hearing |
Red |
|
SSA-1205 |
Disability Hearing Officer's Report of Disability Hearing |
Red |
|
SSA-1207 |
Disability Hearing Officer's Decision |
Red |
|
SSA-1272 |
Subpoena-Disability Hearing |
Red |
|
SSA-1323 |
Report on Individual with Childhood Impairment |
Yellow (Back) |
|
SSA-1560 |
Petition to Obtain Approval of a Fee |
Red |
|
SSA-L1674 |
Disability Hearing Decision Cover Letter-without benefit continuation |
Red |
|
SSA-L1675 |
Disability Hearing Decision Cover Letter-Benefit Continuation Elected at Reconsideration and offered again at ALJ Hearing Level |
Red |
|
SSA-L1677 |
Disability Hearing Decision Cover Letter-Benefit Continuation Not Elected at Reconsideration and Offered Again at ALJ Level |
Red |
|
SSA-L1678 |
Disability Hearing Decision Cover Letter-Without Payment Continuation |
Red |
|
SSA-L1679 |
Disability Hearing Decision Cover Letter-Payment Continuation Not Elected at Reconsideration and Offered Again at ALJ Hearing Level |
Red |
|
SSA-L1680 |
Disability Hearing Decision Cover Letter-Payment Continuation Elected at Reconsideration and Offered Again at ALJ Hearing Level |
Red |
|
SSA-1696 |
Appointment of Representative |
Red |
|
SSA-1697 |
Notice to Representative of Claimant Before the Social Security Administration |
Red |
|
SSA-1709 |
Request for Workers' Compensation/Public Disability Benefit Information |
Orange |
|
SSA-1719s* |
SSI Post-entitlement Direct Input (Discard) |
|
|
SSA-1774 |
Request for Corrective Action (Consistency Review) |
Blue |
|
SSA-2506 |
Psychiatric Review Technique (PRT) Form Completed by DDS Physician or by Treating Physician |
Yellow (Back) |
|
SSA-2514 |
Record of Claimant's Intent to File |
Orange |
|
SSA-2640 |
Disability Hearing Case |
Red |
|
SSA-3023 |
Medical Consultant's Review of Psychiatric Review Technique Form |
Yellow (Back) |
|
SSA-3094 SSA-3341 |
Quality Assurance Review Disability Report - Appeal |
Blue Blue |
|
SSA-3367 |
Disability Report (Field Office) |
Blue |
|
SSA-3368 |
Disability Report–Adult |
Blue |
|
SSA-3369 |
Work History Report |
Blue |
|
SSA-3371* |
Pain Report Child |
Blue |
|
SSA-3375* |
Function Report (Child – Birth to 1st Birthday) |
Blue |
|
SSA-3376* |
Function Report (Child – Age 1 to 3rd Birthday) |
Blue |
|
SSA-3377* |
Function Report (Child – Age 3 to 6th Birthday) |
Blue |
|
SSA-3378* |
Function Report (Child – Age 6 to 12th Birthday) |
Blue |
|
SSA-3379* |
Function Report (Child – Age 12 to 18th Birthday) |
Blue |
|
SSA-3428 |
Determination of Disallowance Coding Sheet |
Yellow (Front) |
|
SSA-3441 |
Disability Report-Appeal |
Blue |
|
SSA-3462* |
Record of SSI Inquiry |
Orange |
|
SSA-3820 |
Disability Report (Child) |
Blue |
|
SSA-3826 |
Medical Report (General) |
Yellow (Back) |
|
SSA-3827 |
Medical Report (Individual with Childhood Impairment) |
Yellow (Back) |
|
SSA-3881 |
Questionnaire for Children Claimant SSI Benefits |
Blue |
|
SSA-3885 |
Government Pension Questionnaire |
Orange |
|
SSA-L4201 |
Letter to Employer Requesting Wage Information |
Orange |
|
SSA-4268 |
Explanation of Determination (Attached to notice) |
Red |
|
SSA-4268 |
Explanation of Determination (Attached to SSA-831–Disability Determination Transmittal) |
Yellow (Front) |
|
HA-4632 |
Claimant's Medications |
Blue |
|
SSA-4734 |
Residual Mental/Physical Functional Capacity (RFC) Assessment – (Completed by DDS Physician) |
Yellow (Back) |
|
SSA-4815 |
Medical Report on Child with Allegation of HIV Infection |
Yellow (Back) |
|
SSA-5002 |
Report of Contact (Non-Disability e.g. P.O.A., AUX INFO) |
Orange |
|
SSA-5002 |
Report of Contact (Non-Medical, e.g., ADL, School Report) |
Blue |
|
SSA-5002 |
Report of Contact (Disability Related, e.g., Lab Findings from T/P) |
Yellow (Back) |
|
SSA-8000* SSA-8001* |
Application(s) for Supplemental Security Income |
Orange |
|
SSA-8006* |
Statement of Living Arrangements, In-kind Support and Maintenance |
Orange |
|
SSA-8010* |
Statement of Income and Resources |
Orange |
|
SSA-8011* |
Statement of Household Expenses and Contributions |
Orange |
|
SSA-8019* |
Third Party Liability Statement |
Orange |
|
SSA-8551 |
Programmatic Fraud Referral |
Blue |
|
No form number |
Electronic Disability Collect System (EDCS) Routing Form |
Blue |
|
(This is a report. No form number is assigned.) |
Report of Investigation (CDI) Place this report on top of ALL documents, including the DDS worksheet. |
Yellow (Back) |
The following is a list of documents received or generated by the hearing office subsequent to request for hearing and the section of the MDF in which they are filed. (Listed in alphabetical order.)
|
Briefs |
Part E |
|
Case History, CPMS |
Part A |
|
Cassette (Hearing) & Cassette Envelope |
Part A |
|
Certificates: |
|
|
Birth |
Part D |
|
Death |
Part D |
|
Congressional Inquiries and Responses |
Part D |
|
Correspondence: |
|
|
Disability Related |
Part E |
|
Non-Disability Related |
Part D |
|
Decision/Dismissal: |
|
|
ALJ |
Part A |
|
Senior Attorney |
Part A |
|
Earnings, Proof of (Certified Earnings Record, Employer Statement, W2, tax return, DEQY/SEQY) |
Part D |
|
Evidence: |
|
|
*Request for |
Part C |
|
Additional Medical |
Part F |
|
Fees: |
|
|
Agreement or Contract |
Part B |
|
Order or Authorization |
Part A |
|
Petition, Form SSA-1560 |
Part B |
|
Hearing: |
|
|
Acknowledgement of Request/Attachments |
Part B |
|
Continuance of Hearing |
Part B |
|
Notice of Hearing (Claimant, Rep., ME, VE) |
Part B |
|
Waiver of Right to Appear |
Part B |
|
Information: |
|
|
Release Form SSA-827 |
Part E |
|
Interrogatories: |
|
|
Medical Expert (ME) |
Part F |
|
Vocational Expert (VE) |
Part E |
|
Printouts, Systems Screen (Not Pertinent) |
Part C |
|
Proffer: |
|
|
ME, request and response |
Part F |
|
VE, request and response |
Part E |
|
Professional Qualification Statements (PQs): |
|
|
Attached to Notice of Hearing (ME/VE) |
Part B |
|
Attached to Medical Evidence |
Part F |
|
Attached to SSA-831-833 |
Part F |
|
Psychiatric Review Technique (PRT) Form |
|
|
Completed by DDS Physician |
Part F |
|
Completed by ALJ |
Part F |
|
Completed by Treating Physician |
Part F |
|
Queries |
Part C |
|
Questionnaires, Disability: |
|
|
Activities of Daily Living (ADL) |
Part E |
|
Claimant's Medication |
Part E |
|
Recent Medical Treatment |
Part E |
|
Work History |
Part E |
|
Reports of Contact: |
|
|
Disability Related |
Part F |
|
Not Disability Related |
Part D |
|
Representative: |
|
|
Appointment of SSA-1696 |
Part B |
|
Withdrawal of |
Part B |
|
Resume (see Professional Qualifications Statement) |
|
|
Substitute Party Form |
Part B |
|
Workers' Compensation Information |
Part D |
* Request will be placed in Part C Current Development/Temporary pending receipt of evidence. If the evidence is not received, the original request and documentation regarding follow-up attempts should be transferred to Part E, Disability Related Development and Documentation, prior to release of the file.
In addition, locally developed forms should be placed in the folder in accordance with guidelines provided in DI 70005.005B.
NOTE:
The Appeals Council will continue to use an Appeals File (AF) to house its working papers.
|
Additional Evidence |
|
|
Briefs |
|
|
Non-medical |
Part D |
|
Medical |
Part E |
|
Cassette |
|
|
Cassettes |
Part A |
|
Cassette Envelopes |
Part A |
|
Search Requests |
AF |
|
Certifications |
Part A |
|
Congressional Correspondence |
|
|
Inquiries |
Part D |
|
Interim Responses |
AF |
|
Final Responses |
Part D |
|
(Other) Correspondence |
|
|
Disability Related |
Part E |
|
Non-Disability Related |
Part D |
|
Interim Correspondence |
AF |
|
Dispositions |
|
|
Decision by AC |
Part A |
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Dismissal by AC |
Part A |
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Notice Denying R/R |
Part A |
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Remand by AC |
Part A |
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Fees |
|
|
Agreement or Contract |
Part B |
|
Order or Authorization |
Part A |
|
Petition |
Part B |
|
MSS Comments |
|
|
Made AC Exhibit |
Part F |
|
Not Made AC Exhibit |
AF |
|
Order Entering Exhibits |
Part D |
|
PRTF |
|
|
(Part of AC Decision) |
Part A |
|
Representative |
|
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Notice of Appointment |
Part B |
|
Withdrawal |
Part B |
|
Request for Review |
Part B |
|
Substitute Party Form |
Part B |
|
Appeals Council Notice(s) – Own Motion, Reopening and Proposed to Find |
Part B |
When a prior hearing decision and the exhibits on which that decision was based are material to the current claim as determined by the ALJ, obtain the prior decision, exhibits and exhibit list, and include them as proposed exhibits for the current case along with the following:
The certified transcript (if one was prepared).
The claimant's request for Appeals Council review of the hearing decision (if one was filed).
A copy of the Appeals Council's final action on the prior claim (if any).
A copy of any documents related to a civil action (if any), including the final action of the court.
NOTE:
Do not renumber the exhibits on which a prior decision was based. Prior hearing documentation will remain intact in the existing folder. These documents will not be incorporated into the MDF. The exhibit list from the prior hearing will be attached to the exhibit list for the MDF. If there is a prior claim that was not appealed to the hearing level, the prior file will remain in its folder and be attached to the back of the current claim MDF. Exhibits relating to second or third hearings, etc., would be prefaced with the letters "B", "C", etc.
EXAMPLES:
B-1A = 2nd hearing, Exhibit 1, part A
C-1DWB = 3rd hearing, Exhibit 1, DWB File
Documents identified as exhibits within each section and part of the claim file will be numbered sequentially. The HO staff will number exhibits in each part beginning with the number 1. The alpha letter applicable to each part, e.g., Part A, must also be included when numbering the exhibits.
Prepare and number the exhibits as follows:
If the exhibit has only one page, place an exhibit number in the lower right hand corner of the page. If the exhibit has more than one page, place an exhibit number in the lower right hand corner of the first page and, on each subsequent page, place the exhibit number, page number, and total number of pages in the exhibit. For example: Exhibit No. 15, Page 2 of 5.
Tape all exhibits smaller than letter size to a sheet of 8-1/2 x 11 inch paper.
Combine all initial, reconsidered (only in non-prototype states) and revised determinations (SSA-831s and SSA- 833s) into one multi-page exhibit. If there are other documents in the same section/part of the file, these should also be made separate exhibits marked as described above.
Prepare the exhibit list. (See I-2-1-20, Preparation of Exhibit List.)
NOTE:
Do not write on, highlight or otherwise mark up exhibits except for stamping and numbering them.
NOTE:
In order to clearly identify the exhibits for any reviewing component which the Administrative Law Judge (ALJ) relied on in making a Decision, exhibits must be selected, arranged and marked in ALL Decision cases. However, in Fully Favorable Decisions, the Exhibit List does not need to be prepared. Thus, in all Fully Favorable Decisions exhibits will still be required to be selected, arranged and marked.