Ssa 455 Ocr Sm – Fill Out and Use This PDF

Why We Are

Writing To

You Now

The Social Security Administration must regularly review the cases of people getting disability beneits to make sure they are still disabled

under our rules. It is time for us to review this case. Enclosed is a Disability Update Report for you to answer to update us about

you (or the person for whom you are the representative payee), your health and medical conditions, any recent work activity, or any recent

training.

If We Don’t Hear From You

If you do not complete and return the report promptly, or tell us why you cannot respond, we may stop sending payments to you. If it is necessary to stop your payments, we will send you another letter telling you what we plan to do.

If We Do A

Full Medical

Review

If we decide to do a full medical review of your case, you can give us any information which you believe shows that you are still disabled,

such as medical reports and letters from your doctors about your health. Then, we look at all your information in your case, including the

new information you give us, and decide whether you continue to be disabled under our rules.

The Privacy

And

Paperwork

Reduction

Acts

Collection and Use of Personal Information - Sections 205(a) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended, and Social Security regulations at 20 C.F.R. 404.1589 and 416.989 authorize us to collect this information. We will use the information you provide to

further document your claim and permit a determination about continuing disability.

The information you furnish on this report is voluntary. However, failure to provide us with the requested information could prevent us from making an accurate and timely decision on your

claim.

We rarely use this information you supply for any purpose other than for reviewing your claim for Social Security beneits. 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 beneits and/or coverage;

2.To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Ofice 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.

GENERAL INSTRUCTIONS

-HOW TO COMPLETE “SCANNABLE” FORMS

The Disability Update Report is a scannable form which can be “read” electronically. To help us process your report, please follow these instructions when you answer the questions on the report form:

1.USE BLACK INK OR A #2 PENCIL.

2.KEEP YOUR NUMBERS, LETTERS, AND “X’S” INSIDE THE BOXES.

3.NUMBERS: Try to make your numbers look like these:

0 1 23456789

4.LETTERS: Print in CAPITALS. Try to make your letters look like these:

AB C DE F G H I J K L M NO P Q R S T U V WX Y Z

5.MONEY AMOUNTS: Show dollars only. Do not use dollar signs

($), and do not show cents. For example, show $1,540.30 like this:

Dollars Only, No Cents

01 , 540

6.DATES: Put a number in each box. For example, show September

9, 2003, like this:

Month Year

0903

QUESTION 6.a -

Have You Been

Hospitalized Or

Had Surgery?

Question 6.b. -

Reason For

Treatment

Place an “X” in the box below “NO” if you have not been hospitalized or

not had surgery during the report period. If you have been hospitalized or had surgery during the report period, then place an “X” in the box below ‘’YES” and answer question 6.b.

Please report your most recent treatment irst and then work backwards in time. Try to provide the most important information. Keep a space between each word. Your medical bills or doctor can provide short, accurate words.

Date of Treatment

Print the month and year you were hospitalized or had surgery. Be sure to use all four spaces. If you were hospitalized more than one month, print last month you were hospitalized.

NOTE: If needed, use the “REMARKS” section on side 2 of the form.

Remarks Section

If you need more room to answer questions l.b., 5.b. and/or 6.b., or

there are any other facts or statements you want us to consider, place an “X” in the box and write in this section. If necessary, use an extra

piece of paper.

Signature, Date

and Telephone

Sections

Please sign the report form as you usually sign your name. Please provide a telephone number where you can be reached during the day.

Disability Update*Report

DATE:

PSC:

TELEPHONE NUMBER

CLAIM NUMBER

or been self-employed?

YES NO

Most

Recent

Work

1.

2.

3.

$

$

$

,

,

,

2. Have you attended any school or work training program(s)

since?

YES NO

my doctor told me I can work.

4. Place an “X” in only one box which best describes your health

WORSE

5. a. Have you gone to a doctor or clinic for treatment

YES NO

Month Year

6. a. Have you been hospitalized or had surgery

since?

b. If you answered “YES” to 6.a., please list:

YES NO