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STATE OF ARKANSAS
a ' 1; 1.26
/14£221,9 Disability Determination For Social Securio,Adminiso*otion
TOLL-FREE #: (844) 455-2755
FAX #: (866) 804-2047
SARAH HUCKABEE SANDERS ARTHUR BOUTIETIE
Governor Diredor
DATE: August 26,2024
TO: Baptist Health Family Clinic Massard
FAX NUMBER: 4797097251
RE: Nancy Larue
9574143
NOTE: The information contained in this facsimile is intended only for the individual or organization named above and may
contain confidential or privileged information. If you are not the intended recipient, any dissemination, distribution or
copying of the communication is prohibited. If you have received this transmission in emor, please notify us by telephone
immediately so that we can airange for the return of all dockmlents treananitted.
DO NOT INCLUDE TH[S PAGE WrTH YOUR RESPONSE
PLEASE SHRED
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.26.2024 16:04:40 Social Security Admin HelpDeek#:8776974889 Page 2/7
VI-/
STATE OF ARKANSAS
r : !·-4.4 Disability Determination For Social Securio,Adminiscadon
»1'But' 79 TOLL-FREE #: (844) 455-2755
':7.4/t~«•
FAX #: (866) 804-2047
SARAH HUCKABEE SANDERS ARTHUR BOUTIETIE
Governor Director
1 8@1%'mawigi
REPLY TO:
SSA S04 AR DDS
RO. Box 8913
London, KY 40742-9741
DATE: August 26,2024 RQID!DCM105605938 SITE:S04 DR:S
SEN:**w****** DOCTYPE:0001 RF:D CS:18bd
PROVIDER: CLAMANT: NANCY LARUE
BAPTIST HEALTH FAMILY CLINIC MASSARD DOB: March 10, 1968
6100 MASSARD RD CASE NUMBER: 9574143
FORI' SMITH, AR 72916 AUTHORIZAT[ON #: 20240826590624
DCPS VENDOR #: 7350440
LEGACY VENDOR #: 1180537-M
TO ENSURE PROPER PAYMENT PLEASE VERIFY PAYEEAND TAX ID INFORMATION
• Payment is allowed by State and Federal guidelines
• The Arkansas DDS is authorized to pay $15 for medical records. If payment is requested, please check below.
FEDERALTAX ID IS REQUIRED
• Unless records and this completed authorization are received within thirty (30) days from August 26,2024, payment
will not be made
• Call (501) 683-3380 with any payment questions
• Records will be paid as-is or the prevailing rate paid by the DDS in the State in which you are located.
Federal Dx ID #:
(Required) Payee Corrections
Check if no records for this claimant Tax ID:
Name:
Check if payment requested Address:
Signed: Telephone #:
(Aurholized AgenI)
Check here to receive faxed evidence requests. Enter your medical records fax number:
Records canbe faxed to: (866) 804-2047
Or mailed inthe envelope provided
Place this page ON TOP of medical evidence
THIS IS AN INVOICE -PLEASE RETURNFOR PAYMENT
Im• Submit records and completed invoice within 30 days ***
ALT Code: 0302
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/2/1,1 -1.4 1. STATE OF ARKANSAS
i:112:,CK!.el Disability Determination For Social Securio,Administration
TOLL-FREE #: (844) 455-2755
FAX #: (866) 804-2047
SARAH HUCKABEE SANDERS ARTHUR BOUTIETIE
Governor Director
Date: August 26,2024
BAPTIST HEALTH FAMILY CLINIC MASSARD Case ID: 9574143
ATTN: MEDICAL RECORDS RE: Nancy Larue
6100 MASSARD RD AKA: Nancy Emery
FORT SMITH AR 72916 Nancy Hampton
Nancy Reith
DOB: March 10, 1968
Vendor Number: 7350440
We ae the office that makes disability decisions for the Social Security Administration. Nancy Larue is applying for or is
receiving disability benefits due to the following conditions: Crohn's disease, HBP, anxiety, ulcerative colitis, COPD
. This is not an authorization to perform an examination.
What We Need From You
To help us evaluate this claim, please send records covering the period of: 10/31/2016 to 12/31/2023.
Include the following information: medical history, psychiatric histoly, clinical findings, laborato]y findings, imaging reports,
treatment prescribed and the response, diagnosis, and progieivis·
Please respond by September 9,2024, We are enclosing a signed HIPAA compliant authorization for the release of medical
records and infonnation.
Please provide a statement based on your findings. Your statement should express your opinion about your patient's abilily to
do work-related physical and/or mental activities despite the limitations or restrictions imposed by her medical condition(s).
For physical impainnents, these activities include sitting, standing, walking, lifting, carrying, pushing, pulling, or other
physical activities (including manipulative or posteal activities, such as reaching, handling, stooping, or crouching); other
activities, such as seeing, heiring, or using other senses; and abil* to adapt to environmental conditions, such as temperature
extremes or fumes. For mental impailments, these activities include understanding; remembering; maintaining concentration,
persistence, or pace; carrying out instructions; and responding appropriately to supervision, coworkers, and work pressures.
If it is determined that we need additional infonnation regarding your patient's impaiiments, would you be willing to perfonn
an examination to provide additional findings? Please contact us if you would be willing to perform this examination. We will
assume that you do not wish to perfolm the examination if you do not respond.
If You Have Any Questions
If you have any questions or wish to provide more infoimation, please call us at the number(s) shown below Monday - Biday
between 8:00 am and 4:30 pm. When you call or leave a message, please provide the Case ID: 9574143, your name, Nancy
Larue's name, and a call back number.
Thank you for your help.
Donna S. 0302
(844) 455·2755
(866) 804·2047 (FAX)
9574143/ Assigned 0302 03/ DCPS / DCM105605938 / OMB No. 0960-0555 / 98022133
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Enclosure(s):
Invoice
Privacy Act and Paperwork Reduction Act Statement
SSA-827 Authorization to Disclose Information to the Social Security Administration (SSA)
9574143/Assigned 0302 03/ DCPS / DCM106605938 / OMB No. 0960-0555 / 98022133
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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 221, 223(d), 1614(4 1631(d), and 1633 of the Social Security Act, as amended, allow us to collect your
information or the infonnation you are submitting on behalf of another, which we will use to detemnine benefits eligibility.
Providing the information is voluntary, but not providing all or part of the information may prevent an accurate and timely
decision on any claim filed. As law permits, we may use and share the information you submit, including with other Federal
agencies, private medical and vocational consultants, contractors, and others, as outlined in the routine uses within System of
Records Notices (SORN) 60-0044, 60-0089, and 60-0320; available at wwlissa.ggitprivacy-, The information you submit
may also be used in computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup
debts under these programs.
Paperwokk ReductionAct Statement - This infonnation collection meets the requirements of 44 U.S.C. & 3507, as amended
by section 2 of the paperwork Red,irtion A.et 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 12 minutes to read the
instructions, gather the facts, and answer the questions. Send gab. commencs regarding this burden estimate or any other
aspect of this collection, including suggestions pr reducing this burden above to: SSA, 6401 Security Blvd, Battimore, MD
21235-6401.
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Form Appovad
WHOSE Records to be Disclosed CM@ B. 09600823
NAME Fint, Middle, Last, Sumx)
Nancy Larue
SSN -- --Birthday
431·41-2102 (mnidd,0 03/10/68
AUTHORIZATION TO DISCLOSE INFORMATION TO
THE SOCIAL SECURITY ADMINISTRATION (SSA)
" PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW "
I voluntarily authorize and request disclosure (including paper, oral, and electronic Interchang&):
OF WHAT A# my modical records: also education recard, and other information related to my ability to
pe,form taaks. This inclutle, specific permission to_Inlgale:
1. All record$ 0nd othef information regarding my tmatment, hoipitalization, ind 0*atient care for my impairment{$)
mil*#aq. and nat_limititin:
· Psychological, psychiatric or other mental impairmellt(s) (excludes »psychotheraly notes" as defined in 45 CFR 164,501 )
Drug abuse. alcoholism, or other substance abuse
• Sidde cell anamia
• Records which may indicate the presence of a communicablu Or floncommunicable disease; and tests for or records of HIWAIDS
· Gene-related impairmenls (induding genetic test reBults)
2. Information about how my impairment(5) affects my ability to complete tasks and activities of daily living, and affects my ability to wd.
3. Cople; Ofedugationaltests or evaluations, including Individualized Educational Programs, triennlal assessments, psychological and
speech evatuations, and any oth®r records that can help evaluate runction; also teacherj' Observations and evaluations,
4. Information greated within 12 months after the date this authorization is signed, as well as past information.
FROM WHOM THIS BOX TO BE COMPLETED BY SSA#DDS (as needed) Additional infornation to identify
the subject (e-g., other names used), the specific source, or the material to be disclosed:
· All medical sources (hospitals, dinics, labs,
phyglelans, payehologists etc.) including
mental health, correctional, addiction BAFIET HEALTH FAMILY CLImC MASSARD
ArTN; MEDICAL RECORDS
treatment, and VA health care faclities 6100 MASSARD RD
• All educational sources (schools, teachers,
FORTSMMH. AR 72916
records adrninistrators, counselors, ate.) 10/31,2016 TO 1281,2023
· Social worke[5/rehabilitatkn counselors
• Consulting examiners Used by SSA
• Employers, insurance companies, workert
compensation programs
· Others who may know ~I,Jut my gondition
(family, neighbors, friends, public ofAcials)
TO WHOM The Social Security Administration and tothe State agency authorized to process my ¢*Se (usually called "disability
determination services"), Including contract copy sorvlces, and doctors or other professional# conmulted during the
pmee*$. [Al@o, for interna~onal claims, to the U.S. Depaltment of State Fleign Service Post ]
PURPOSE Determining my allglblllty for benefits, including looking at the combined effect & any impairmants
mat by mernseives would Mot meet SSA'# der,Ition of disability, and whether I tan mznage such benefits.
¤ Determining whether I ann capable of managing benefits ONLY (check only if this applies)
EXPIRES WHEN This Mulhorization is good for 12 months from the date signed (below my signature).
lauthorize the use of a copy (induding electronic copy) of thls form forthe disclosure of the information described above.
· I understand that there are some circumstances in which this information may be fedisclo5ed to other parties (see page 2 for details)
I may ¥/ite to GSA and my sources to revoke this autholization at any timc (sce paige 2 for details).
• SSAwillgive me a copy ofthis form iflask: I maya@kthe Sourge to allowme toin,pect orgel a oopy of material to bedisolosed.
· I have read both pages of this form and agree to the disclosures above from the types of sources listed.
RICASE SIGN USING BLUE OR BLACK INK ONLY IF not signed by subject of disclosure, specify basis for authority to sign
AL authorizing digdosure El Parent of minor mGuardian g] Other personal representailve (explain)
L Sectfunicailysignedby
SIGN PNancy (perent/guaraian/personal representative sign A
Larue
here W twosignattres required by State law) ~
Date Signed Street Address
08/2624 1402 GARYSTREET
Phone Number (with area code) City State ZIP
479-259-7010 FORTSMI™ AR 72901
,WITNESS I know the person signing this forn or am satisfied of this person's identity
A AttestedbySSAoroes,gnatedSureAgency*loyee; IF needed. second witness sign here (e.g.. if signed with "X" above)
SIGN //D5rnart SIGN *
-11.11~ I-
Phone Number (or Address) Phone Number (or Address)
844-455-2755 LIFITLE ROCK AR 72201-3926
This generd *Ind Spxial authorization to disolose Was developed to comply with the provisions regarding disclosure of medical, eduoational, and
Dther InTormalion under P.L. 10+191 CHIPAA'), 45 CFR parts 160 and 164: 42 U.S. Code section 290<a·-2, 42 CFR part 2, 38 U.S. Gode section
7332; 38 CPR 1.475; 20 U.S, Code section 12329 ("FERPA'), 34 CFR parts 99 and 300, and State law.
Form 5SA-827 (11-2012) ef (11-2012) Use 4-2009 and Later Editions Until Supply is Exhausted Pag,1 of 2
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08.26,2024 16:07:38 Social Security Admin HelpDesk#:8776974889 Page 7/7
Explanation of Form GSA-827,
"Authorization to Disclose Information to the Social Security Administration (SSA)"
We need your written authorization to help get the information required to process your claim, and to determ Ine your
capability of managing beneflts. Laws and regulations require that souroes of personal information have a signed
authorization before releasing itto us. Also, laws require specific authorization forthe release ofinfonnation about certain
conditions and from educational sources.
You oan provide this authorization by signing a form SSA-827. Federal law permits sources with information about you to
release that information If you sign a single authorization to release all your information from all your possible sources. We
will make copies of it for each source- A covered entity (that is, a source of medical information about you) may not
condition treatment, payment, enrollment, or eligibility for benefits on whether you sign this authorization form. A few
States, and some individual sources of information, require that the authonzation specifically name the source that you
authorize to release personal information. In those cases, we may ask you to sign one authorization for each source and
we may contact you again if we need you to sign more authorizations.
You have the right to revoke this authorization at any time, except to the extent a source of information has already relied
on It to take an action. To revoke, send a written statement to any Social Security Office- If you do, also send a copy
directly to any of your sources that you no longer wish to disclose information about yQU; SSA can tell you if we identified
any sources you didn't tell us about, SSA may use information disclosed prior to revocation to decide your claim.
It is SSA's policy to provide service to people with limited English proficiency in their native language or preferred mode of
communication consistent with Executive Order 13166 (August 11, 2000) and the Individuals with Disabilities Education
Act SSA makes every reasonable effort to ensure that the information in the SSA-827 is provided to you In your native or
preferred language.
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 22301 and 1631(d) of the Social Security Act, as amended, allow us to colleot this information.
Furnishing us thls information 1% voluntary, However, failing to provide all or part of the Information may prevent us from
making an accurate and timely deoision on your claim that could result in a denial or loss of benefits-
We will use the Information you provide to determine your eligibility or continuing eligibiljty for benefits, and your ability to
manage any benefits that you currently receive.
We may also share your information for the following purposes, called routine uses'
1. To State audit agencies for auditing State supplementation payments and Medicaid eligibility considerations;
2. To third party contacts where necessary to establish or verify information provided by representative payees or
payee applicants; and
3. To FederaL State or local agencies for administering cash or non-cash income maintenance or health
maintenance programs-
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 veriry 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 (SORNs) 60-0089, entitled
Claims Folders Systems, 60-0090, entitled Master Benericlary Record; 60-0320, entitled Electronic Disability; and 60-
0103,entitled Supplemental Security Income Record and Special Veterans Benefits, Additional information and a full
listing ofall our SORNs are available on our website at ew,§29!alsggl[Ily,g.oy/foia/bluebook
Pal,envork Reduction Act Statement
This information collection meets the requirements of 44 U.S,C. § 3507, as amended by section 2 of the Paperwork
Reduotion Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and
Budget control number. We estimate that it will take about 10 minutes to read the Instructions, gatherthe facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
You can find your local Social Security omce through SSA's website at www,soo alsecurity-gov. Offices are also
listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-
1213 (TTY 1-800-325-0778). You may send oomments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-8401. Send only comments relating to our #me estimate to this address, not the completed
form.
