Individuals receiving disability benefits face periodic reviews to ensure the continued accuracy and eligibility of their status, a process that is facilitated through the Social Security Administration's SSA-454-BK form, also known as the Continuing Disability Review Report. This form plays a crucial role in determining whether a recipient's medical conditions still qualify them for disability benefits. It solicits comprehensive information, including current medical providers, medication details, and any changes in the beneficiary's condition or treatment over the past 12 months, without needing to collect medical records from doctors or hospitals directly. Recipients are encouraged to fill out the report as thoroughly as possible, with the availability of assistance from the Social Security Office, via interpreters if necessary, to ensure clarity and completeness. Besides personal and contact information, the form asks for data on vocational rehabilitation, employment, or other support services accessed since the last decision. With its careful design to safeguard privacy, the form specifies that providing this information is voluntary, but incomplete responses might impact the accuracy and timing of the review decision. Designed to streamline the review process while minimizing the burden on the individuals undergoing evaluation, this form exemplifies the SSA's effort to administer disability benefits efficaciously and empathetically.
| Question | Answer |
|---|---|
| Form Name | Form SSA-454-BK |
| Form Length | 12 pages |
| Fillable? | Yes |
| Fillable fields | 1 |
| Avg. time to fill out | 3 min 12 sec |
| Other names | 454 bk, social security disbiliy review packet, ssa gov form 454, ssa 454 bk |
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Discontinue Prior Editions |
Page 1 of 12 |
Social Security Administration |
OMB No. |
CONTINUING DISABILITY REVIEW REPORT
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The office that reviews your medical condition(s) will use the information you provide in this report to decide whether you are still disabled. Please complete as much of the report as you can.
IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask your health care provider to complete this report. If you cannot complete the report, you may contact us at
WHAT YOU NEED TO COMPLETE THIS REPORT
•Name, address, and phone number of a friend or relative (other than your doctors) we can contact who knows about your medical condition(s), and can help with your case, if needed.
•Name, address, and phone number of any health care providers you have seen within the last 12 months. (You may be able to get that information from the telephone book, Internet, online medical chart, medical bills, prescriptions, or prescription medicine containers.)
•Any prescription or
•Name of organization who we can contact that would have medical information about your condition(s) in the last 12 months. (Such as social services agencies, welfare agencies, attorneys, prisons, workers’ compensation and insurance companies who have paid you disability benefits.)
•Information about any education since your last disability decision. (See top of Page 3 for date of last decision.)
•Information about any vocational rehabilitation, employment, or other support services since your last disability decision. (See top of Page 3 for date of last decision.)
•ANSWER EVERY QUESTION, unless the report indicates otherwise. If you do not know an answer, or the answer is "none" or "does not apply," please write: "don't know," or "none," or "does not apply."
•If you need more space to answer any question, please use Section 9 - Remarks, on the last page to finish your answer. Write the number of the question you are answering.
YOUR MEDICAL RECORDS
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS. If you have consented to us obtaining medical records from your providers, we will request your records directly from them. The information that you give us on this report tells us where to request your medical and other records.
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Page 2 of 12 |
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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 221(i), 223(d), 1614(a), 1631(e), and 1633(c) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claim filed.
We will use the information to determine eligibility for benefits. We may also share your information for the following purposes, called routine uses:
•To applicants, claimants, prospective applicants or claimants, other than the data subject, their authorized representatives or representative payees to the extent necessary to pursue Social Security claims and to representative payees when the information pertains to individuals for whom they serve as representative payees, for the purpose of assisting Social Security Administration (SSA) in administering its representative payment responsibilities under the Act and assisting the representative payees in performing their duties as payees, including receiving and accounting for benefits for individuals for whom they serve as payees; and
•To private medical and vocational consultants for use in making preparation for, or evaluating the results of, consultative medical examinations or vocational assessments which they were engaged to perform by SSA or a State agency acting in accord with sections 221 or 1633 of the Act.
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 verify 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 (SORN)
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act 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 60 minutes to read the instructions, gather the facts, and answer the questions. Send only comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD
SEND OR BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL SECURITY OFFICE, OR THE NEAREST U.S. EMBASSY OR CONSULATE OFFICE. Office addresses are listed under U.S. Government agencies in your telephone directory or you may call
(TTY
AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET
AND KEEP IT FOR YOUR RECORDS.
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Discontinue Prior Editions |
Page 3 of 12 |
Social Security Administration |
OMB No. |
CONTINUING DISABILITY REVIEW REPORT
For SSA Use Only - Do not write in this box.
Date of your last medical disability decision:
SECTION 1 - INFORMATION ABOUT YOU
When a question refers to "you" or "your" it refers to the person receiving disability benefits. If you are completing this report for someone else, please provide information about them.
1.A. NAME (First, Middle, Last, Suffix)
1.B. SOCIAL SECURITY NUMBER
1.C. In the last 12 months, have you used any other names on your medical or educational records? Examples include maiden name, other married names, other names, or nickname.
YES
NO
If YES, please list names used
1.D. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable.
CITY
STATE/Province ZIP/Postal Code COUNTRY (if not USA)
1.E. Is your residence address the same as your mailing address? 
YES 
NO - Complete RESIDENT ADDRESS below
RESIDENT ADDRESS (Include apartment number if applicable.)
CITY
STATE/Province ZIP/Postal Code COUNTRY (if not USA)
1.F. DAYTIME PHONE NUMBER(S) where we can call to speak with you, or leave a message, if needed. (Include area code, or IDD and country code if outside the USA or Canada.)
Primary: |
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1.G. EMAIL ADDRESS |
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1.H. Can you speak and understand English? |
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NO |
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If NO, what language do you prefer? |
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If you cannot speak and understand English, we will provide an interpreter free of charge.
1.I. Can you read and understand English? |
YES |
NO |
1.J. Can you write more than your name in English? |
YES |
NO |
SECTION 2 – SOMEONE WE CAN CONTACT |
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Please provide the name of someone (other than your doctors) we can contact who knows about your medical condition(s), and can help with your case and can help us reach you if you become unavailable. Examples include a family member, friend, or neighbor.
2.A. NAME (First, Middle Initial, Last)
2.B. Relationship to Person in 1.A.
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2.C. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable.
CITY
STATE/Province ZIP/Postal Code COUNTRY (if not USA)
2.D. DAYTIME PHONE NUMBER (as described in 1.F. above) |
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2.E. Can this person speak and understand English? |
YES |
NO |
(If NO, what language is preferred?) |
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SECTION 3 - MEDICAL INFORMATION
Please provide us with general medical information to assist us with any records requests. We will use this information to see what additional questions or forms we may need to send you.
3.A. Separately list each physical and/or mental health condition that limits your ability to work. If under age 18, list the physical and/or mental health condition(s) that limit the child’s ability to do the same things as other children the same age.
1.
2.
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4.
5.
If you need more space to list additional conditions go to Section 9 – Remarks
3.B. What is your height? |
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3.C. What is your weight? |
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kilograms |
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3.D. Within the last 12 months, have you seen or received treatment from a health care provider (doctor, hospital, clinic, psychiatrists, nurse practitioners, therapists, physical therapists, or other medical professionals)?
NO (Go to 3.F.)
YES (Complete the following section below.)
You may find this information on medical bills or the internet. If you don’t have the full street address, give as much as you can. Example: “On Main St next to the Courthouse.”
1. NAME OF FACILITY OR OFFICE |
NAME OF HEALTH CARE PROVIDER THAT TREATED YOU |
What medical conditions were treated or evaluated?
PHONE NUMBER
STREET ADDRESS
DATE LAST SEEN
(IF KNOWN)
MM / YYYY
CITY
STATE/Province ZIP/Postal Code COUNTRY (if not USA)
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2. NAME OF FACILITY OR OFFICE |
NAME OF HEALTH CARE PROVIDER THAT TREATED YOU |
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What medical conditions were treated or evaluated? |
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3. NAME OF FACILITY OR OFFICE |
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OF HEALTH CARE PROVIDER THAT TREATED YOU |
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What medical conditions were treated or evaluated?
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4. NAME OF FACILITY OR OFFICE |
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What medical conditions were treated or evaluated?
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5. NAME OF FACILITY OR OFFICE |
NAME |
OF HEALTH CARE PROVIDER THAT TREATED YOU |
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What medical conditions were treated or evaluated?
PHONE NUMBER |
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If you need to list more facilities or doctors, use Section 9 – Remarks.
3.E. Within the last 12 months, did any of the providers listed in 3.D. order any medical tests for you? (Include tests already performed and those scheduled in the future, and the healthcare provider that scheduled them.)
NO (Go to 3.F.)
YES (Complete the following section below.) – If you need more space, use Section 9 – Remarks.
TEST |
NAME OF HEALTHCARE PROVIDER |
Blood test (not HIV)
Breathing test
Cardiac catheterization
EEG (brain wave test)
EKG (heart test)
Hearing test
HIV test
Speech/language test
Treadmill (exercise test)
Vision test
Psychological/IQ test
Biopsy (list body part):
MRI/CT scan (list body part):
Other – please specify:
3.F. Within the last 12 months, have you taken or are you now taking any prescription or
medicines?
NO (Go to 3.G.)
YES (Complete the following section below.) – Look at your medicine containers, if necessary. If you need more space, use Section 9 – Remarks.
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IF PRESCRIBED, GIVE |
REASON FOR MEDICINE |
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DOCTOR NAME |
(IF KNOWN) |
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3.G. Do you use an assistive device?
NO (Go to Section 4)
YES (Complete the following section below.) If you need more space, use Section 9 – Remarks.
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FREQUENCY OF USE |
NAME OF HEALTH CARE |
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PROVIDER, IF PRESCRIBED |
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Braces |
Always |
Sometimes |
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Canes |
Always |
Sometimes |
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Crutches |
Always |
Sometimes |
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Eyeglasses |
Always |
Sometimes |
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Hearing aid |
Always |
Sometimes |
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Screen reader |
Always |
Sometimes |
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Walker |
Always |
Sometimes |
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Wheelchair |
Always |
Sometimes |
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Other: |
Always |
Sometimes |
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3.H. Is the person receiving disability benefits listed in 1.A. under age 14?
NO (Go to Section 4)
YES (Go to Section 10)
SECTION 4 – WORK INFORMATION
Complete only if you are age 14 years old or older
Please tell us if you have worked since the date of your last medical disability decision. If we have any additional questions about your work, we may contact you.
4.A. Since the date of your last medical disability decision have you worked? (See date on top of Page 3.)
NO (Go to 4.B.)
YES (Complete following section below.)
Are you currently working?
No
Yes
Select all types of work you had since your last medical disability decision:
Wages from employer
4.B. Is the person receiving disability benefits listed in 1.A. under age 18?
NO (Go to Section 5)
YES (Go to Section 10)
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Page 8 of 12 |
SECTION 5 – SUPPORT SERVICES
Complete only if you are age 18 years or older
Please provide the information about your participation in support services. Examples of support services can include:
•An Individualized Education Program (IEP) through a school (if a student age
•An individualized work plan with an employment network under the Ticket to Work Program
•A Plan to Achieve
•An individualized plan for employment with a vocational rehabilitation agency or any other organization.
5.A. Since the date of your last medical disability decision, have you participated or are you participating in any support services mentioned above or any other vocational rehabilitation, employment services, or other support services to help you return to work? (See date on top of Page 3.)
NO (Go to Section 6)
YES (Complete the following section below.)
FACILITY OR ORGANIZATION NAME |
PHONE NUMBER |
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COUNSELOR, INSTRUCTOR, OR JOB COACH NAME |
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MAILING ADDRESS (Street or PO Box) (Include Suite, Building, etc.) |
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STATE/Province ZIP/Postal Code COUNTRY (if not USA)
5.B. Are you still participating in the plan or program? (Select answer below)
YES - Date began: |
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Expected completion date: |
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5.C. What types of services, tests, or evaluation were provided?
Select all that apply:
Vision test |
Psychological/IQ test |
Work classes |
Hearing test |
Work Evaluation |
Other - Please explain: |
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SECTION 6 - OTHER MEDICAL INFORMATION
Complete only if you are age 18 years or older
Please provide the contact information for anyone else or any other organization that may have medical information about your physical or mental health condition(s) that you did not list in Questions 3.D. or 5.A.
6.Within the last 12 months, does anyone else (other than your medical providers) have your medical information or are you scheduled to see anyone else? Examples include places like social services agencies, welfare agencies, attorneys, prisons, workers’ compensation, insurance companies who have paid you disability benefits.
NO (Go to Section 7)
YES (Complete the following section below.)
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NAME OR ORGANIZATION |
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PHONE NUMBER |
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MAILING ADDRESS |
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NAME OF CONTACT PERSON |
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CLAIM NUMBER |
(if any) |
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Date of First Contact |
Date of Last Contact |
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Reason(s) for Contacts |
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If you need to list other people or organizations use Section 9 - Remarks and give the same detailed information as above for each one you list.
SECTION 7 – EDUCATION, TRAINING, AND LITERACY
Complete only if you are age 18 years or older
Please provide any information about your education, training, and literacy since your last disability decision.
7.A. Have you received any education since your last disability decision? (See date at the top of Page 3.)
NO, (Go to 7.B.)
YES (Complete the following section below.)
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NAME OF SCHOOL |
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DATE(S) OF ATTENDANCE |
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7.B. Have you received any type of training (specialized job, trade, or vocational training) since your last
disability decision? (See date at top of Page 3.)
NO (Go to 7.C.)
YES (Complete the following section below.)
NAME OF TRAINING FACILITY |
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PHONE NUMBER |
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7.C. What written language do you use every day in most situations (at home, work, school, in community,
etc.)?
7.D. READING - In the language you identified in 7.C., can you read a simple message, such as a
shopping list or short and simple notes? |
YES |
NO |
7.E. WRITING - In the language you identified in 7.C., can you write a simple message, such as a shopping
list or short simple notes? |
YES |
NO |
If you need to list other education information or training facilities use Section 9 - Remarks and
provide the same detailed information as above.
SECTION 8 - DAILY ACTIVITIES
Complete only if you are age 18 years or older.
Please tell us how your conditions affect your everyday life. This will help us further understand your medical condition(s).
8.A. Describe what you do in a typical day. Please focus on how your medical condition(s) affect your daily activities. If you need more space, use Section 9 – Remarks.
8.B. Do you have hobbies or interests? If you need more space, use Section 9 – Remarks.
YES |
NO |
If YES, please describe what they are and how much time you spend doing them.
8.C. Do your medical conditions cause you to have difficulties doing any of the following?
YES |
NO |
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Dressing |
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Taking medicine |
Doing chores (inside/outside of house) |
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Bathing |
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Preparing meals |
Driving or using public transportation |
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Caring for hair |
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Feeding self |
Understanding or following directions |
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Walking |
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Shopping |
Managing money |
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Standing |
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Lifting objects |
Getting along with people |
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Sitting |
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Using arms |
Using hands or fingers |
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Concentrating |
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Remembering |
Seeing, hearing, or speaking |
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Please explain anything you marked you need help with or have difficulty doing:
If you need more space, use Section 9 – Remarks.
