Ha 4632 Form – Fill Out and Use This PDF

SOCIAL SECURITY ADMINISTRATION				Form Approved
Office of Hearings and Appeals				OMB No. 0960-0289
		CLAIMANT'S MEDICATIONS
A.	To be completed by Hearing Office
(Claimant and Social Security Number)			(Wage Earner and Social Security Number)	Thelasttimewebrought
			(Leave blank if same as claimant)	your case up-to-date was:
	- -		- -
B.	To be completed by the claimant
		PLEASE PRINT

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		PHYSICIAN
DOSAGE

PLEASE LIST BELOW THE NONPRESCRIPTION MEDICATION YOU ARE TAKING AND THE REASONS YOU TAKE THEM.

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 re-evaluate the decision on your claim.

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 federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

A complete use of routine uses for this information is available in our Systems of Records Notices, 60-0009, Hearings and Appeals Case Control System, and 60-0010, Hearing Office Tracking System of Claimant Cases. These notices, additional information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at any 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 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 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form HA-4632 (10-2012) ef (10-2012) Use Until Stock Is Exhausted