Form HA-4631: Claimant's Recent Medical Treatment

Form HA-4631 PDF Details

To be completed by the Claimant: please print and answer the following questions.

Above date: the last time the case was brought up-to-date is in A, to be completed by Hearing Office.

Doctors: have you been treated or examined by a doctor (other than a doctor at a hospital) since the above date?

Hospital: have you been hospitalized since the above date? If yes, list the name and address of the hospital, why you were hospitalized and what treatment you received.

More space: if more space is needed, use additional sheets.

Voluntary: providing the information is voluntary, but not providing all or part of the information may prevent an accurate and timely decision on any claim filed.