Last Update: 9/28/05 (Transmittal I-2-67)
Exhibit 1 — First Request for Hearing
Claimant: John Doe SSN: 123-45-6789
Exh. No. |
Part No. |
Description |
No. of Pages |
---|---|---|---|
|
|
PAYMENT DOCUMENTS/DECISIONS |
|
1 |
A |
Initial Disability Determination by State Agency, Title II, dated May 25, 1994 (with attached rationale) |
4 |
2 |
A |
Reconsideration Disability Determination by State Agency, Title II, dated November 22, 1994 (with attached rationale) |
4 |
|
|
JURISDICTIONAL DOCUMENTS/NOTICES |
|
1 |
B |
Social Security Notice Dated May 25, 1994 |
3 |
2 |
B |
Request for Reconsideration filed July 26, 1994 |
4 |
3 |
B |
Social Security Notice of Reconsideration dated November 23, 1994 |
4 |
4 |
B |
Request for Hearing filed December 20, 1994 |
2 |
|
|
NON-DISABILITY DEVELOPMENT |
|
1 |
D |
Leads/Protective Filing Worksheet dated January 2, 1994 |
2 |
2 |
D |
Application for Disability Insurance Benefits filed January 31, 1994 |
4 |
3 |
D |
Earnings record (dated/certified) February 5, 1994 |
4 |
|
|
DISABILITY RELATED DEVELOPMENT AND |
|
1 |
E |
Vocational Report dated February 8, 1994 |
6 |
2 |
E |
Supplemental Questionnaire dated March 16, 1994 |
6 |
3 |
E |
Reconsideration Disability Report dated June 30, 1994 |
5 |
4 |
E |
Claimant's Statement When Request for Hearing is Filed and the Issue is Disability dated December 9, 1994 |
3 |
|
|
RECEIVED DURING HEARING |
|
1 |
E |
List of Claimant's Medications dated December 10, 1994 |
2 |
|
|
MEDICAL RECORDS |
|
1 |
F |
Medical records covering period from January 15, 1990 to June 30, 1994, from General Hospital |
56 |
2 |
F |
Psychiatric Review Technique Form by SA, dated May 25, 1994 |
|
3 |
F |
Hospital Records for admission on March 17, 1994 through discharge on March 24, 1994, from General Hospital |
7 |
4 |
F |
Medical Report dated July 30, 1994, by Dr. C. M. Bones |
3 |
5 |
F |
Professional Qualifications, Dr. C. M. Bones |
1 |
|
|
SUPPLEMENTAL SECURITY INCOME (SSI) |
|
1 |
SSI |
Record of SSI Inquiry dated January 2, 1994 |
1 |
2 |
SSI |
Application for Supplemental Security Income Benefits filed January 31, 1994 |
6 |
3 |
SSI |
Initial Disability Determination by State Agency, Title XVI, dated May 25, 1994 (with attached rationale) |
4 |
4 |
SSI |
Supplemental Security Income Notice dated May 25, 1994 (with attached rationale) |
3 |
5 |
SSI |
Reconsideration Disability Determination by State Agency, Title XVI, dated November 22, 1994 (with attached rationale) |
4 |
6 |
SSI |
Supplemental Security Income Notice of Reconsideration — Disability dated November 23, 1994 |
3 |
Exhibit 2—Subsequent Request for Hearing
Claimant: John Doe SSN: 123-45-6789
Exh. No |
Part No. |
Description |
No. of Pages |
---|---|---|---|
|
|
PAYMENT DOCUMENTS/DECISIONS |
|
B-1 |
A |
ALJ's decision dated December 15, 1994, Notice of Decision, and list of exhibits marked #1 through #25. |
11 |
B-2 |
A |
Initial Disability Determination by State Agency, Title II, dated December 20, 1994 (with attached rationale) |
4 |
B-3 |
A |
Reconsideration Disability Determination by State Agency, Title II, dated January 5, 1995 (with attached rationale) |
4 |
|
|
JURISDICTIONAL DOCUMENTS/NOTICES |
|
B-1 |
B |
Social Security Notice dated December 20, 1994 |
3 |
B-2 |
B |
Request for Reconsideration filed December 22, 1994 |
4 |
B-3 |
B |
Social Security Notice of Reconsideration dated January 5, 1994 |
4 |
B-4 |
B |
Request for Hearing filed January 10, 1995 |
2 |
|
|
NON-DISABILITY DEVELOPMENT |
|
B-1 |
E |
Disability Report dated December 20, 1994 |
8 |
B-2 |
E |
Vocational Report dated December 20, 1994 |
6 |
B-3 |
E |
Supplemental Questionnaire dated December 21, 1994 |
6 |
B-4 |
E |
Reconsideration Disability Report dated December 22, 1994 |
5 |
|
|
MEDICAL RECORDS |
|
B-1 |
F |
Hospital Records for admission on September 10, 1994 through discharge on November 15, 1994, from General Hospital |
7 |
Exhibit 3 — Appeals Council or Court Remand Cases
Claimant: John Doe SSN: 123-45-6789
PAYMENT DOCUMENTS/DECISIONS
Exh. No. |
Part. No. |
Description |
No. of Pages |
---|---|---|---|
3 |
A |
Decision by ALJ issued on January 15, 1995 |
8 |
|
|
JURISDICTIONAL DOCUMENTS/NOTICES |
|
5 |
B |
Request for Review of Hearing Decision/Order filed January 17, 1995 |
2 |
6 |
A |
Action of Appeals Council on Request for Review dated January 20, 1995 |
4 |
|
|
NON-DISABILITY DEVELOPMENT |
|
DISABILITY RELATED DEVELOPMENT AND DOCUMENTATION | |||
|
|
MEDICAL RECORDS |
|
AC-1 |
F |
Appeals Council Exhibit — Medical Report dated November 30, 1994, from Dr. C. M. Bones |
2 |
AC-2 |
F |
Appeals Council Exhibit — Medical Report dated December 5, 1995, from DR. C. M. Bones, Jr. |
2 |
AC-3 |
F |
Appeals Council Exhibit — Professional Qualifications of Dr. C. M. Bones, Jr. |
1 |
5 |
F |
Medical records covering period from January 15, 1994 to June 30, 1994, from General Hospital |
36 |
6 |
F |
Hospital Records for admission on March 17, 1994 discharge on March 24, 1994, from General Hospital |
7 |
EXHIBITS ADMITTED AT SUPPLEMENTAL HEARING HELD ON JANUARY 27, 1995 FOLLOWING REMAND | |||
7 |
F |
Outpatient Medical Records covering period from November 15, 1994 to January 20, 1995, from General Hospital |
8 |
ADDITIONAL CLAIM FILE, IF APPLICABLE:
Part (SSI) - Supplemental Security Income
Part (DWB) - Disabled Widow/Widower
Part (CDB) - Child's Disability Benefits