How to Fill Out and Submit the SSA Telehealth CE Agreement Form

The SSA telehealth consultative examination agreement form (OMB No. 0960-0555) is a short consent document that Disability Determination Services mails you when your existing medical records are not enough to decide your disability claim and DDS wants to hold the consultative exam by video instead of in person. You have 10 days from the date on the cover letter to sign and return it. If you do nothing, DDS will simply schedule a traditional in-person exam instead.1Social Security Administration. POMS DI 22510.014 – Telehealth Consultative Examination Agreement and Notice

Why DDS Sent You This Form

SSA only pays for a consultative examination when the medical evidence already in your file is insufficient, unavailable, or inconsistent.2Social Security Administration. 20 CFR 404.1519a – When We Will Purchase a Consultative Examination Once DDS decides an exam is needed, it may offer you the telehealth option before scheduling a physical visit.

DDS contacts you either by phone or by letter. If an examiner reaches you by phone and gathers everything during the call, no paper form is needed. When the contact comes by mail, the agreement form arrives with a cover letter and a barcoded sheet, and it has to be filled out and sent back.1Social Security Administration. POMS DI 22510.014 – Telehealth Consultative Examination Agreement and Notice

What the Form Asks

Your name is already printed on the form by DDS, so you are not filling in your identifying information. The rest is four numbered items and a signature block.3Social Security Administration. SSA Telehealth Consultative Examination Agreement Form

Question 1: Do You Agree to a Telehealth Exam

Check Yes or No. There is no penalty for declining. If you check No, DDS schedules an in-person exam instead. You can also change your mind later and switch to in-person at any point before the appointment happens.

Question 2: The Four Requirements

If you checked Yes, you confirm four things:

  • You have access to a private, indoor, quiet space where you can attend the exam without interruptions.
  • You have a reliable internet connection.
  • You have a device with a working camera and microphone. A smartphone, tablet, laptop, or desktop is fine for most exams. For a speech and language exam, a smartphone is not acceptable, and the device must have at least a 9.7-inch diagonal screen.4Social Security Administration. POMS DI 22510.013 – Telehealth Consultative Examination – General
  • You have a valid, unexpired, government-issued photo ID to show on camera at the exam.

If you answer No to any of these, telehealth likely will not work, and DDS will arrange an in-person visit.

Question 3: You Can Withdraw

This item confirms you understand you can withdraw your agreement to telehealth at any time before the appointment. Check Yes to acknowledge it.

Question 4: Email Address

Write the email address where you want appointment details and the video link sent. Check it carefully. A typo here can mean you never receive the login information on the day of the exam.

Signature

Sign, print your name, and date the form. A parent completing it for a minor child, or a legal guardian acting for someone else, signs in that capacity.3Social Security Administration. SSA Telehealth Consultative Examination Agreement Form

How to Return It

The cover letter states your deadline, typically 10 days from the letter’s date. Use black or blue ink. You have two ways to send it back:

  • Mail it in the pre-addressed envelope that came with the form.
  • Fax it to the number on the cover sheet. Fax is usually faster.

Either way, put the barcode page on top. That barcode ties the paperwork to your electronic disability file, and leaving it off delays processing.3Social Security Administration. SSA Telehealth Consultative Examination Agreement Form

Once DDS logs the completed form, it authorizes a contracted medical provider to conduct the evaluation and mails you a formal appointment notice with the provider’s name, the date and time, and the video platform to use.1Social Security Administration. POMS DI 22510.014 – Telehealth Consultative Examination Agreement and Notice

If You Don’t Return the Form

Not returning the form doesn’t stop your claim. DDS will schedule an in-person consultative examination instead.1Social Security Administration. POMS DI 22510.014 – Telehealth Consultative Examination Agreement and Notice

The bigger risk is missing the exam itself, whether telehealth or in-person. Under federal regulation, if you fail or refuse to attend a consultative examination without a good reason, SSA may find that you are not disabled. If you already receive benefits, SSA may find that your disability has ended.5eCFR. 20 CFR 404.1518 – If You Fail to Appear at a Consultative Examination

Good reason is judged case by case, taking into account any physical, mental, educational, or language limitations. If something is going to keep you from the appointment, call your DDS examiner before the date and ask to reschedule.5eCFR. 20 CFR 404.1518 – If You Fail to Appear at a Consultative Examination

Getting Ready for the Video Appointment

SSA publishes a tip sheet for claimants attending a telehealth consultative exam. Following it matters because a technical failure during the session can force a reschedule and delay your claim.6Social Security Administration. Tip Sheet – Preparing for a Telehealth Consultative Examination

The room:

  • Sit with your chair facing away from bright windows so the provider sees your face, not a silhouette.
  • Be ready to open blinds, close them, or turn on lights if the provider asks.
  • Turn off fans, televisions, and radios, and silence your phone.

The device:

  • Update your web browser ahead of time.
  • Plug the device in or make sure it is fully charged.
  • Test the camera, microphone, and volume before the exam.
  • Click the video link a few minutes early so you are ready when the provider joins.

Keep your unexpired government-issued photo ID within reach. The provider will ask to see it on camera at the start of the session. You do not need to install any special software in advance; the appointment notice will tell you what platform to expect and how to access it.

Also make sure you are alone in the room. If someone walks in during the exam, the provider may pause or reschedule, because the examiner needs confidence that no one else is coaching your answers or listening in.

Speech and Language Exams Have Extra Rules

If your consultative examination is for speech and language, telehealth requirements are stricter. A smartphone will not work. You need a tablet with a screen of at least 9.7 inches diagonally, a laptop, or a desktop monitor.4Social Security Administration. POMS DI 22510.013 – Telehealth Consultative Examination – General

Interpreters are not permitted for these exams. If your primary language is not English, DDS must select an examiner who is fluent in your language. For a child whose primary language is Spanish, the examiner must use standardized tests published in Spanish.4Social Security Administration. POMS DI 22510.013 – Telehealth Consultative Examination – General