Ssa Form Ha 4631 PDF Details

Understanding the Social Security Administration's Form HA-4631, known as the "Claimant's Recent Medical Treatment" form, is crucial for individuals undergoing the appeals process for Social Security benefits. This form serves as a vital tool for claimants to provide up-to-date medical information that can significantly impact the outcome of their appeal. Specifically, it's designed to collect recent details about a claimant’s medical treatment, exams by doctors outside of hospital settings, and any hospitalizations that have occurred since the last update provided to the Social Security Office of Hearings and Appeals. Claimants are required to list the names, addresses, and phone numbers of doctors who have examined or treated them, including dates of these medical interactions. Additionally, they must describe the nature of their hospital visits, the treatment received, and how their conditions have been explained to them by medical professionals. Failure to provide comprehensive and precise information might delay or affect the benefits process. The form not only facilitates a thorough evaluation of the claimant’s current health status but also underscores the Administration's commitment to ensuring decisions are made with the most current and relevant information. With sections allocated for detailed responses and the provision for attaching additional sheets if necessary, this form embodies a pivotal step in advocating for one's health rights within the Social Security benefits framework.

QuestionAnswer
Form NameSsa Form Ha 4631
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesha form, what is handover form, how form habit, ssa form ha 4631

Form Preview Example

Social Security Administration

Form Approved

Office of Hearings and Appeals

OMB No. 0960-0292

 

 

 

CLAIMANT'S RECENT MEDICAL TREATMENT

A. To be completed by hearing office

(Claimant and Social Security Number)

(Wage Earner and Social Security Number)

 

 

(Leave blank if same as claimant)

 

 

-

-

-

-

 

 

 

 

The last time we brought your case up-to-date was:

B. To be completed by the claimant

PLEASE PRINT

Please Answer the Following Questions:

 

 

 

(1) Have you been treated or examined by a doctor (other than a doctor at a hospital)

 

 

since the above date?

u

Yes

No

(If yes, please list the names, addresses and telephone numbers of doctors who have treated or examined you since the above date. Also list the dates of treatment or examination. If possible, send updated reports from these doctors to the Administrative Law Judge before the date of your hearing.)

DOCTORS NAME(S)

ADDRESS(ES) & TELEPHONE NO.(S)

DATE(S)

(2) What have these doctors told you about your condition?

(3) Have you been hospitalized since the above date?

 

u

Yes

No

 

(If yes, please list the name and address of the hospital. Also, explain why you were hospitalized and what treatment you received.)

Name of Hospital

Address of Hospital (Include ZIP Code)

 

 

Reason for hospitalization:

 

 

 

 

 

Treatment received:

Form HA-4631 (6-2010) ef (6-2010) Destroy Old Stock

If more space is needed, use additional sheets.

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (C) of the Social Security Act, as amended, authorize us to collect this information. The information you provide will be used to determine whether we need to obtain additional information regarding your treatments or conditions.

The information you furnish on this form is voluntary. However, failure to provide the requested information may prevent you from receiving benefits under the Social Security Act.

We generally use the information you supply for the purpose of determining eligibility for benefits. 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 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 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.

Additional information regarding this form, routine uses of information, and our programs and systems, is available on-line at www.ssa.gov or at your 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 10 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD

21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form HA-4631 (6-2010) ef (6-2010)

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Pay close attention while filling in this form. Make sure that all required blanks are filled out accurately.

1. Whenever filling in the form ha 4631, be certain to include all needed fields in its associated section. It will help to expedite the work, which allows your details to be handled efficiently and correctly.

Filling out part 1 of ssa ha 4631

2. Your next step is usually to fill out these particular fields: Have you been hospitalized since, u Yes, If yes please list the name and, Name of Hospital, Address of Hospital Include ZIP, Reason for hospitalization, and Treatment received.

Step # 2 for filling in ssa ha 4631

It's very easy to make errors while completing your Name of Hospital, so make sure that you reread it prior to deciding to finalize the form.

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