Form Ssa 546 PDF Details

When you are applying for Social Security Disability benefits, it is important to submit all of the required forms. One of the most important forms is Form SSA 546, which is used to certify your medical condition. This form must be completed by your doctor and submitted with your application. Here's what you need to know about Form SSA 546. Form SSA 546 is used to certify your eligibility for Social Security Disability benefits. This form must be filled out by your doctor and submitted with your application. The information on this form will help Social Security assess whether you are eligible for disability benefits and determine the severity of your impairment. If you are planning to apply for Social Security Disability benefits, make sure you complete and submit Form SSA 546 along with your application. Your doctor will need to fill out this form in order to provide accurate information about your medical condition. Failure to submit this form could result in a delay or denia

QuestionAnswer
Form NameForm Ssa 546
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 546 compensation, social security form 546, ssa 546, social security 546

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Social Security Administration

Form Approved

 

OMB No. 0960-0247

WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFIT QUESTIONNAIRE

NAME OF WORKER

SOCIAL SECURITY NUMBER

Privacy Act Statement

Collection and Use of Personal Information

Section 224 of the Social Security Act, as amended, authorizes us to collect this information. We will use this information to determine the effect of your worker's compensation or other public disability benefit on your Social Security disability insurance benefits.

Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent us from making an accurate and timely decision on your benefit eligibility.

We rarely use the information you supply for any purpose other than for determining the effect of other disability benefits on your Social Security benefits. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following:

1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veterans' Affairs);

3.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and,

4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, state or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

A complete list of routine uses for this information is available in Systems of Records Notices entitled, Claims Folder Record, 60-0089, and Master Beneficiary Record, 60-0090. These notices, additional information regarding this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.

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 control number. We estimate that it will take about 12.5 minutes to read the

instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is 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 comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

1. What type of benefit are you receiving, did you receive or do you expect to receive in connection with your disability?

WORKERS' COMPENSATION:

Workers' Compensation - State (including) occupational disease payments)

Black Lung Benefits

Longshore and Harbor Workers' Compensation

Federal Employees' Compensation (FECA- workers' compensation for Federal employees)

PUBLIC DISABILITY BENEFITS:

Civil Service Disability or Federal Employees' Re- tirement System (FERS) Disability Benefits

State Temporary Disability Payments

Federal, State or Local Government Employee Disability Benefits

Other:

2. For each benefit checked above, enter the claim number, employer, insurance carrier and date of injury/illness.

TYPE OF BENEFIT

CLAIM NUMBER

EMPLOYER

INSURANCE CARRIER

DATE OF INJURY/ILLNESS

3.Indicate the State in which you worked when these benefits began or, if workers' compensation is one of the benefits involved, the State in which the injury occurred.

STATE

4. If you are receiving one of the public disability benefits listed in item 1, were Social Security taxes always paid on your earnings?

Yes

No

(If "No," explain. For example, you were a federal, State or local government employee whose earnings

were not covered or were not always covered by Social Security.)

5.Indicate the status of your claim for workers' compensation or other public disability benefits. If you are receiving more than one type of benefit, indicate the status of each claim.

a.

 

Filed for Benefits, or Intend to File but not yet

d.

 

 

 

 

Entitled

 

 

 

Currently Receiving Benefits

b.

c.

Filed for Benefits, but Claim was Denied

e.

Claim Denied; Appeal Pending (if appeal is pend- ing,

f.

give date you expect a decision.)

 

Date

 

Received Payments in the Past but not Presently

Other (e.g., lump-sum payment) Explain:

If a., b., or c. is checked, go on to Item 11 (signature block). If d., e., or f. is checked, complete the remainder of the form.

6. How are (or were) those disability payments made?

Weekly

Monthly

Every Two Weeks

Other (Explain):

FORM SSA-546 (2-2012) EF (2-2012) Destroy prior editions

7.a. List the amount(s) and the period(s) of time for which those disability benefits were made. (if only lump-sum payment was made, see item 8.)

TYPE OF BENEFIT

AMOUNT

FROM

TO

b. If those payments have stopped, indicate the reason:

Lump-Sum Settlement Pending

Permanent Rating Pending

c. Do you expect those payments to begin again?

Yes

Appeal Pending

Other (Explain in item 10, "Remarks")

No

IF "YES", WHEN (Date)

 

 

 

8.

Have you ever received or been awarded a lump-sum settlement (including

Yes (If "Yes",

 

 

"compromise and release" or similar type of settlement)?

 

 

 

 

 

 

complete item 9)

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Lump-sum payment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Date(s) settlement(s) or award(s) made

 

 

 

 

 

b. Gross Amount(s)

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. The lump sum represents:

 

 

 

 

 

 

 

 

 

$

 

per week for

 

weeks beginning

 

 

 

 

d. The amount shown in 9.b. (Gross amount) includes:

(1) MEDICAL EXPENSES OF

(2) ATTORNEY FEES OF

(3) RELATED EXPENSES OF

$

$

$

 

 

 

10. Remarks:

 

 

 

 

 

 

 

 

IMPORTANT INFORMATION. PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW

I agree to report if I apply for or begin to receive a workers' compensation (including black lung benefits) or a public disability benefit or the amount that I am receiving changes or stops, or I receive a lump-sum settlement. I understand that such benefits may affect my Social Security payments or result in an overpayment which I may have to pay back.

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

SIGNATURE OF PERSON MAKING STATEMENT

DATE

 

 

 

SIGNATURE (First Name, Middle Initial, Last Name) (Write in Ink)

TELEPHONE NUMBERS(S) at which

SIGN

you may be contacted during the day

 

 

HERE u

(

)

 

 

 

MAILING ADDRESS (Number Street, Apt. No., P.O. Box., Rural Route)

 

 

 

 

 

CITY AND STATE

ZIP CODE

 

 

 

 

Witnesses are required ONLY if this form has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the person requesting reconsideration must sign below, giving their full addresses.

(1) SIGNATURE OF WITNESS

(2) SIGNATURE OF WITNESS

 

 

ADDRESS (Number and Street, City, State and ZIP Code)

ADDRESS (Number and Street, City, State and ZIP Code)

 

 

FORM SSA-546 (2-2012) EF (2-2012)