Form HA-4632 at a glance
What it is: Form HA-4632, Claimant's Medications, is a form of the Social Security Administration Office of Disability Adjudication.
Section B is to be completed by the Claimant.
Sections 205, 223, 702, 1614, 1631, and 1869 of the Social Security Act, as amended, allow the Social Security Administration to collect this information, which it will use to determine benefits eligibility.
A filled-in Form HA-4632 example: a claimant lists two prescription medications
How to fill out Form HA-4632, box by box
A. To be completed by Hearing Office
Section A is to be completed by the Hearing Office.
Section A has a line for the Claimant and Social Security Number and a line for the Wage Earner and Social Security Number (leave blank if same as claimant).
Section A also has a line for the last time the Social Security Administration brought your case up-to-date.
Prescription medication which you are presently taking
List 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.
For each prescription medication, enter the Name of Medication & Dosage, the Date First Prescribed, the Daily Amount Taken, the Reason for Medication and the Name of Physician.
Please print.
Nonprescription medication you are taking
List the nonprescription medication you are taking and the reasons you take them.
More rules for Form HA-4632
If more space is needed, use additional sheets.
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.
The Social Security Administration estimates that it will take about 2 minutes to read the instructions, gather the facts, and answer the questions.
Sources
[1] Form HA-4632 (08-2026), Claimant's Medications, Social Security Administration (the Official source link on this page).