HA-4632: Social Security Claimant's Medications

Form HA-4632 PDF Details

Part A is to be completed by Hearing Office. Part B is to be completed by the Claimant.

Prescription medication: list the prescription medication which you are presently taking.

Medication name: if the name of the medication is not shown on the prescription container, you may verify the name with your pharmacist.

Nonprescription medication: list the nonprescription medication you are taking and the reasons you take them.

More space: if more space is needed, use additional sheets.

Voluntary: providing this information is voluntary, but not providing all or part of the information may prevent an accurate and timely decision on any claim filed.