"Exhibit - Fedmer Social Security Disability Eligibility Statement"

Exhibit - Fedmer Social Security Disability Eligibility Statement is a 1-page legal document that was released by the U.S. Office of Personnel Management and used nation-wide.

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Exhibit – FEDMER Social Security Disability Eligibility Statement
Federal Medical Evidence of Record (FEDMER)
Social Security Disability Eligibility Statement
Keep a copy of this form
Name_____________________________SSN__________________________________
Please put a check mark in the box next to the number that describes your situation, and follow the instructions for that section.
1. I am already receiving Social Security disability benefits. I will provide my Human Resource office with
proof (e.g. copy of my Social Security Award Certificate).
2. I have filed for Social Security disability benefits, but I have not received a decision. I will provide my
Human Resource office with proof (e.g., copy of Social Security disability application receipt, copy of the
ISBA page “What You Need to Do Now”, etc.).).
If you checked either #1 or #2 above, sign and date the statement below, and return it to your Human
Resource office with the documentation indicated. Do not check any further blocks, or take any other
action.
My signature below verifies my status.
Signature: ___________________________________________
Date: _________________
If you have not checked Box 1 or 2, above, please check Box 3 and follow the instructions.
3. I have not filed for Social Security disability benefits, OR I have filed and have been denied. Since I am
now filing for FERS disability, I understand I also need to file for Social Security disability benefits.
If you checked block #3, you need to apply for Social Security disability using either the:
Internet to complete the “Online Adult Disability Report” and the "Online Application for Social Security
benefits" at
http://www.socialsecurity.gov/applyfordisability/adult.htm
OR
Contact Option: Contact Social Security to schedule an appointment to file your Social Security disability
claim. You can call Social Security’s national toll-free telephone number (1-800-772-1213) or contact your
local Social Security office. When you make your appointment, Social Security will provide you with an
“Adult Disability Starter Kit” that you can use to prepare for your interview. You can also see the starter kit
at the Internet site shown above.
Whether you use the Internet or the Contact Option to file, a Social Security representative will contact you to
complete your disability application. At that time you will need to provide to Social Security a copy of this
form and a copy of any medical records you have obtained for your FERS disability claim.
When you file your disability application, Social Security will provide you with a receipt. You must provide your
Human Resource office with a copy of the application receipt, which is needed by them in order to complete
the processing of your FERS disability application.
Under FEDMER (the Federal Medical Evidence of Record program), Social Security will:
1) Use the medical records you provide to expedite the processing of your Social Security disability claim. (If additional
medical evidence is needed to process your disability application, the State Agency making the decision will let you
know.)
2) Share a copy of the medical decision with the Office of Personnel Management (OPM). When your Social Security
disability claim is processed, Social Security will send a copy of any award or denial notice to the U.S. Office of Personnel
Management (OPM), Claims 1 Group, Room 4458, 1900 E St. NW, Washington D.C. 20415, Attn: FEDMER.
Exhibit – FEDMER Social Security Disability Eligibility Statement
Federal Medical Evidence of Record (FEDMER)
Social Security Disability Eligibility Statement
Keep a copy of this form
Name_____________________________SSN__________________________________
Please put a check mark in the box next to the number that describes your situation, and follow the instructions for that section.
1. I am already receiving Social Security disability benefits. I will provide my Human Resource office with
proof (e.g. copy of my Social Security Award Certificate).
2. I have filed for Social Security disability benefits, but I have not received a decision. I will provide my
Human Resource office with proof (e.g., copy of Social Security disability application receipt, copy of the
ISBA page “What You Need to Do Now”, etc.).).
If you checked either #1 or #2 above, sign and date the statement below, and return it to your Human
Resource office with the documentation indicated. Do not check any further blocks, or take any other
action.
My signature below verifies my status.
Signature: ___________________________________________
Date: _________________
If you have not checked Box 1 or 2, above, please check Box 3 and follow the instructions.
3. I have not filed for Social Security disability benefits, OR I have filed and have been denied. Since I am
now filing for FERS disability, I understand I also need to file for Social Security disability benefits.
If you checked block #3, you need to apply for Social Security disability using either the:
Internet to complete the “Online Adult Disability Report” and the "Online Application for Social Security
benefits" at
http://www.socialsecurity.gov/applyfordisability/adult.htm
OR
Contact Option: Contact Social Security to schedule an appointment to file your Social Security disability
claim. You can call Social Security’s national toll-free telephone number (1-800-772-1213) or contact your
local Social Security office. When you make your appointment, Social Security will provide you with an
“Adult Disability Starter Kit” that you can use to prepare for your interview. You can also see the starter kit
at the Internet site shown above.
Whether you use the Internet or the Contact Option to file, a Social Security representative will contact you to
complete your disability application. At that time you will need to provide to Social Security a copy of this
form and a copy of any medical records you have obtained for your FERS disability claim.
When you file your disability application, Social Security will provide you with a receipt. You must provide your
Human Resource office with a copy of the application receipt, which is needed by them in order to complete
the processing of your FERS disability application.
Under FEDMER (the Federal Medical Evidence of Record program), Social Security will:
1) Use the medical records you provide to expedite the processing of your Social Security disability claim. (If additional
medical evidence is needed to process your disability application, the State Agency making the decision will let you
know.)
2) Share a copy of the medical decision with the Office of Personnel Management (OPM). When your Social Security
disability claim is processed, Social Security will send a copy of any award or denial notice to the U.S. Office of Personnel
Management (OPM), Claims 1 Group, Room 4458, 1900 E St. NW, Washington D.C. 20415, Attn: FEDMER.