Navigating the complexities of Social Security benefits can often seem daunting, especially when dealing with health-related issues which require thorough documentation. The HA-4631 form serves as a critical document for individuals who are in the process of appealing decisions related to their Social Security benefits. Specifically designed by the Social Security Administration Office of Hearings and Appeals, this form plays a crucial role in updating one's medical treatment information. Claimants are required to detail recent treatments or examinations by doctors outside of hospital settings, including the names, addresses, and phone numbers of the treating physicians, as well as the dates of treatment. Moreover, it seeks information about any hospitalizations, the reasons for such stays, and the treatments received. Completing this form accurately is essential, as it helps the Administrative Law Judge understand the current state of the claimant’s health and make informed decisions regarding their eligibility for benefits. Additionally, the form includes a section imparting the importance of privacy, outlining how and why the provided information might be used or disclosed, in accordance with Federal laws. This highlights the administration's commitment to maintaining claimants' privacy while also fulfilling its mandate. The HA-4631 form, thereby, represents a fundamental step in ensuring that individuals receive the benefits they require, guided by a clear process that respects their confidentiality and the sensitivity of their medical information.
| Question | Answer |
|---|---|
| Form Name | Form Ha 4631 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | CLAIMANTS, omb no 0960 0292, Bldg, form approved omb 0960 0292 |
Social Security Administration |
Form Approved |
Office of Hearings and Appeals |
OMB No. |
CLAIMANT’S RECENT MEDICAL TREATMENT
A. To be completed by hearing office
(Claimant and Social Security Number) |
(Wage Earner and Social Security Number) |
|
(Leave blank if same as claimant) |
The last time we brought your case up-
B. To be completed by the claimant
PLEASE PRINT
Please Answer the Following Questions:
(1) Have you been treated or examined by a doctor (other than a doctor at a hospital)
since the above date? |
Yes
No
(If yes, please list the names, addresses and telephone numbers of doctors who have treated or examined you since the above date. Also list the dates of treatment and examination. If possible, send updated reports from these doctors to the Administrative Law Judge before the date of your hearing.)
DOCTORS NAME(S)
ADDRESS(ES) & TELEPHONE NO.(S)
DATE(S)
(2) What have these doctors told you about your condition?
(3) Have you been hospitalized since the above date? |
Yes
No
(If yes, please list the name and address of the hospital. Also, explain why you were hospitalized and what treatment you received.)
Name of Hospital |
Address of Hospital (Include ZIP Code) |
|
|
Reason for hospitalization: |
|
|
|
|
|
|
|
Treatment received:
Form |
PLEASE READ PRIVACY ACT |
If more space is needed, |
Issue Old Stock |
STATEMENT ON REVERSE |
use additional sheets. |
PRIVACY ACT AND PAPERWORK ACT NOTICE
The Social Security Act (sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869 (b)(1) and (c), as appropriate) authorizes the collection of information on this form. We will use the information on your medical treatment to help us decide if we need to obtain more information. You do not have to give it, but if you do not you may not receive benefits under the Social Security Act. We may give out the information on this form without your written consent if we need to get more information to decide if you are eligible for benefits or if a Federal law requires us to do so. Specifically, we may provide information to another Federal, State, or local government agency which is deciding your eligibility for a government benefit or program; to the President or a Congressman inquiring on your behalf; to an independent party who needs statistical information for a research paper or audit report on a Social Security program; or to the Department of Justice to represent the Federal Government in a court suit related to a program administered by the Social Security Administration.
We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree with it.
Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number.
TIME IT TAKES TO COMPLETE THIS FORM
We estimate that it will take you about 10 minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. If you have comments or suggestions on this estimate, write to the Social Security Administration, ATTN: Reports Clearance Officer,