Are you unsure about how to fill out the Ha 4632 Form for your next tax filing? Don't worry, we've got you covered! In this blog post, our team of experienced tax specialists will be walking through the process step by step. We'll give you all the information you need so that submitting your taxes is a breeze--from describing what information is required on each line of the form to providing tips and tricks on how to streamline the submission process. Read on to learn more about everything related to filing with an Ha 4632 form!
Question | Answer |
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Form Name | Ha 4632 Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | claimant form download, ssa ha, social claimant, social security ha 4632 |
SOCIAL SECURITY ADMINISTRATION |
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Form Approved |
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Office of Hearings and Appeals |
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OMB No. |
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CLAIMANT'S MEDICATIONS |
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A. |
To be completed by Hearing Office |
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(Claimant and Social Security Number) |
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(Wage Earner and Social Security Number) |
Thelasttimewebrought |
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(Leave blank if same as claimant) |
your case |
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- - |
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- - |
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B. |
To be completed by the claimant |
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PLEASE PRINT |
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PLEASE LIST BELOW THE PRESCRIPTION MEDICATION WHICH YOU ARE PRESENTLY TAKING. IF THE NAME OF THE MEDICATION IS NOT SHOWN ON THE PRESCRIPTION CONTAINER, YOU MAY VERIFY THE NAME WITH YOUR PHARMACIST.
NAME OF |
DATE FIRST |
DAILY AMOUNT |
REASON FOR MEDICATION |
NAME OF |
MEDICATION & |
PRESCRIBED |
TAKEN |
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PHYSICIAN |
DOSAGE |
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PLEASE LIST BELOW THE NONPRESCRIPTION MEDICATION YOU ARE TAKING AND THE REASONS YOU TAKE THEM.
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If more space is needed, use additional sheets.
Privacy Act Statement Collection and Use
of Personal Information
Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended authorize us to collect this information. We will use this information to evaluate your reason for failing to appear at your scheduled hearing.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the requested information may affect our ability to
We rarely use the information you supply for any purpose other than for determining problems in Social Security programs. 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;
2.To comply with Federal Laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and the Department of Veterans’Affairs);
3.To make determinations for eligibility in similar health and income maintenance programs as at the Federal, State, and local level; and
4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security programs.
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
A complete use of routine uses for this information is available in our Systems of Records Notices,
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 15 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
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