The HA-1152-U3 form is a critical tool used by the Social Security Administration, specifically within the Office of Disability Adjudication and Review, to assess an individual's mental capacity to perform work-related activities. This Medical Source Statement of Ability to Do Work-Related Activities (Mental) is meticulously designed to capture a professional opinion based on medical history, clinical findings, and prognosis regarding the claimant's ability to function in a work setting on a sustained basis, defined as eight hours a day, five days a week. The form breaks down various mental activities into categories such as understanding and remembering instructions, interacting appropriately with others, and responding to changes in a work setting, asking the medical professional to rate the claimant's limitations as none, mild, moderate, marked, or extreme. It emphasizes the importance of providing factors that support the assessment, essentially requiring the healthcare provider to substantiate their evaluation with concrete evidence. Additionally, the form touches on whether impairments related to alcohol or substance abuse contribute to the limitations identified, and whether the individual can manage benefits in their own best interest. The Privacy Act and Paperwork Reduction Act statements at the end underline the legal and ethical considerations in handling personal information, highlighting the form's role in a larger bureaucratic and privacy-sensitive ecosystem.
| Question | Answer |
|---|---|
| Form Name | Form Ha 1152 U3 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | RFQ1236 427_ExF medical source statement pdf form |