Form SSA-454-BK Continuing Disability Review Report

Form Approved OMB No. 0960-0072

DRAFT Social Security Administration

CONTINUING DISABILITY REVIEW REPORT

SSA-454-BK

PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT

The office that reviews your medical condition will use the information in this report. The
information will help that office decide whether you are still disabled. Please complete as
much of the report as you can.
IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask
your health care provider to complete this report. If you cannot complete the report, a Social
Security Representative will assist you. If you have an appointment, please have the
completed report ready when we contact you.
Note: If you are assisting someone else with this report. please answer the questions as if that
person were completing the report.
HOW TO COMPLETE THIS REPORT

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• Print or write clearly.
• Include a ZIP or postal code with each address.
• Provide complete phone numbers including area code. If a phone number is outside the
United States, also provide international direct dialing (100) code and country code.
• If you cannot remember the names and addresses of your health care providers, you may
be able to get that information from the telephone book, Internet, medical bills,
prescriptions, or prescription medicine containers.
• ANSWER EVERY QUESTION, unless the report indicates otherwise. If you do not know
an answer, or the answer is "none" or "does not apply," please write: "dontt know," or
"none," or "does not apply."
• Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
• If you need more space to answer any question, please use Section 11 - Remarks, on the
last page to finish your answer. Write the number of the question you are answering.

R

YOUR MEDICAL RECORDS

D

If you have any of your medical records covering the last 12 months, send or bring them to our
office with this completed report. Please tell us if you want to keep your records so we can .
return them to you. If you are having an interview in our office, bring your medical records, your
prescription medicine containers (if available), and the completed report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS
THAT YOU DO NOT ALREADY HAVE. With your permission, we will request your r~cofa8Y .
The information that you give us on this report tells us where to request your medical and other
records.

FORM SSA 454-BK Paper v23 10/06/09

.

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a), 223(d), and 163l(e)(1) ofthe Social Security Act, as amended, authorize us to collect this
infonnation. The infonnation you provide will be used to make a decision on the named claimant's claim. Your
response is voluntary. However, failure to provide all or part of the requested infonnation could prevent an
accurate and timely decision on the named claimant's claim.
We rarely use this infonnation provided on this fonn for any other purpose other than for the reasons explained
above. 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 F ederallaws 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 at the Federal,
State, and 10callevel; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social
Security programs.

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We may also use this information you provided in computer matching programs. Matching programs co~prui bur
records with records kept by other Federal, State or local government agencies. Infonnation from these matching
programs can be used to establish or verifY a person's eligibility for Federally-funded and administered benefit
programs and for repayment of payments or delinquent debts under these programs.

10
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A complete list of routine uses for this information is available in Systems of Records Notice 60-0089. The'
notice, additional infonnation regarding this fonn, and information regarding our programs and systems,
available on-line at www.socialsecurity.gov or at your local Social Security Office.

ate" "

The Paperwork Reduction Act

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This infonnation collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 ofthe
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 60 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 Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed report.
,

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SEND OR BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL SECURITY OFFICE, .... ,
THE NEAREST U.S EMBASSY OR CONSULATE OFFICE. You can find your local Social Security." .
office through SSA's website at www.socialsecurity.gov. Offices are also listed under U.S. Government
agencies in your telephone directory or you may call 1-800-772-1213 (TTY 1-800-325-0778) for the address.
''">\,~,

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AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT
FOR YOUR RECORDS
.

FORM SSA 454-BK Paper v 18 06/09/09

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S

Social Secu

Administration

Form

OMB No.

CONTINUING DISABILITY REVIEW REPORT
. Use Only - Do not write in thi$ box.
Use Remarks Section ifmo:reSP~lce
,'ii,}"'i"iiii,i",,~'i'"''

Related SSN _ _--.;...;............._ _ _ __

Type(s) of Cases(s)

THletl

0

DIS

0

DWB

d

" COB

O.

(Check all thi11t apply.)

TltleXVl

0

Of

0

os

0

DC

n

81

MEDlCALDISABILITY
If you are filling out this report for the disabled person, please provide information about him or her. When a
question refers to "you," "your," or the "disabled person," it refers to the person receiving disability benefits.

Mailing Address (Street or POBox) Include apartment number if applicable
City

ZIP/Postal Code

ntry (if not USA)

1. D Daytime Phone Number, including area code, and the IDD and country codes if you live outside the USA or
Canada.
Phonenumber __~__~__~____~_______
o Check this box if you do not have a phone or a number where we can leave a message.

1. E. Alternate
Alternate
number
. 1. F Can you speak and understand English?
i

No

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Yes

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If no, what language do you prefer?
k and understand
If
cannot
1. G Have you used any other names
your
are maiden name, other married name, or nickname.
If
list them here

on

apartment number if

R

:fCMailing Address (Street or

D

me Phone Number (as described in 1.E above)
2. E Can this person speak and understand English?
If no, what language is preferred?

t_

FORM SSA 454-BK Paper v23 10/06/09

any

9

we may reach you,

Yes

No

Exampl~~

2. F Who is completing
report?
o The disabled person listed in 1.A
o The person listed in 2.A
o Someone else
the rest of Section 2
2. G Name (First. Middle Initial. Last)

2. H Relationship to Disabled Person

2. I Daytime Phone Number
2. J Mailing Address (Street or POBox) Include apartment number if applicable.
City

!

State/Province

Country (if not

ZIP/Postal

3. A If you are an adult (age 18 or older). list the physical and/or mental condition(s) (including em
or
learning problems) that limit your ability to work. If you are completing this report for a child (under age 18),
list the physical and/or mental condition(s) (including emotional or learning problems) that limit the child's abilityto
do the same things as other children of the same age. List each physical and/or mental condition separately;

3.
4.

9

5.

.......................

i""'i-BWhat'isyo~rheightwii~h'o"utshoes?''''

··············-·~OR

on page 12

.......~. ~-.~~~- . . -~-. ".". ~--~---,

inches

10
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feet

3. C What is your weight without shoes?

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you need more space, go to Section 11 -

centimeters (if outside USA)

OR

pounds

kilograms (if outside USA)

4. Since the date of your last medical disability decision have you worked? (See date at top of Page 1)

D No

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D Ves (If yes, we may contact you for additional information)

D

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Within the last
you seen a doctor or
care professional or rgr,"I\I~.n
, hospital or clinic, or do you have a future appointment scheduled:
5. A For any phYSical condition(s)
DVes

DNo

5. B For any mental condition(s) (including emotional or learning problems)
DVes

DNo

If you answered "No" to both 5. A and 5. B go to Section 6 Other Medical Information on page 9
FORM SSA 454-BK Paper v 18 06/09/09

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5. C Tell us who may have medical records covering the last 12 months about any your
or mental
condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals (including
emergency room visits). clinics. and other health care facilities. Tell us about your next appointment. if you
have one scheduled.
Name of healthcare professional who treated you
I Name of Facility or Office

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.

!

I City

~-.~

----"-,~~

...-"..

'"""

ZIP/Postal Code

State/Province

Country (if not USA)

..

,,""'

I

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient visits
First Visit

2. Emergency Room visits
List the most recent date first

Last Visit
Next scheduled appointment

3. Overnight hospital stays

A.

A. Date in

Date out

B.

B. Date in

Date out

C.

C. Date in

Date out

...~.

(if any)

!

What medical conditions were treated or evaluated?

9

I

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II

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What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box;)

.,

Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or has
scheduled you to take. Please give the dates for past and future tests. If you need to list more tests, use Section
11 - Remarks on the last page.
0 Check this box if no tests by this provider or at this facility.
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......... " ...... ,....,,"""""""................. ................_._._._...... ...............,,'-"'_ ................

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0

Kind of Test
EEG (brain wave test)

:0 Treadmill (exercise test)

0

HIV Test

0

Cardiac Catheterization

0

Blood Test (not HIV)

0

Biopsy (list body part)

0

X-Ray (list body part)

0

Hearing Test

0

MRIICT Scan (list body part)

0

SpeechlLanguage Test

Dates of Tests

R

0

D

1

Kind of Test
EKG (heart test)

••••••••••••••••••••••••••••••••••• "w. . . . . . . _

.0 Vision Test
0

----... .....

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Dates of Tests
..

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>

'P'·

0

Other (please describe)

Breathing Test

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,:;

)
, ••,

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If you do not have any more doctors or hospitals to describe, go to Section 9 on page 9. .

FORM SSA 454-BK Paper v 18 06/09/09

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•••.•

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5. 0 Tell us who may have medical records covering
months about any of your nn,,,cu.r-.21 nr~m"nl'l"l
condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you
have one scheduled.
Name of healthcare professional who treated you ~
Name of Facility or Office
!

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.

Patient ID# (if known)

! City

-

---~~-~

! State/Province

ZIP/Postal Code

!

I! Country (ifnofUSA)

l
Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient visits
First Visit

2. Emergency Room visits
List the most recent date first
A.

Last Visit
Next scheduled appointment

3. Overnight hospital stays
A. Date in

Date out

B.

B. Date in

Date out

C.

C. Date in

Date out

...

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~-~

(if any)
What medical conditions were treated or evaluated?

i

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

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10

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• Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or has
• scheduled you to take. Please give the dates for past and future tests. If you need to list more tests, use Section
i 11 - Remarks on the last page.
0 Check this box if no tests by this provider or at this facility.

0

Kind of Test
EKG (heart test)

0

0

Kind of Test
EEG (brain wave test)

Treadmill (exercise test)

0

HIVTest

0

Cardiac Catheterization

0

Blood Test (not HIV)

~,c i.~

0

Biopsy (list body part)

0

X·Ray (list body part)

~

0

Hearing Test

0

MRIICT Scan (list body part)

0

Speech/Language Test

0

Vision Test

0

Breathing Test

D

R

Dates of Tests

Dates of Tests
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, '.:

.. '

~ "

. ,~

~ ;.~

~ .: ~

0

Other (please describe)

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 9.

FORM SSA 454-BK Paper v 18 06/09/09

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5. E Tell us who may have medical records covering the last 12
about any of your physical or rru,.nTl:a1
condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you
have one scheduled.
Name of Facility or Office
Name of healthcare professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.

~

_

...........----.-.....-.- .. -.. -.-......................................_---_.. ..- .............................._.................._.........._._----­

Phone Number
.
, Mailing Address

.-------------.

Patient ID#

----~.----~----..------~--------------------~

-1 State/ProVince

City

ZIP/Postal Code

Country (if not

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient visits
First Visit _ _ _ __

2. Emergency Room visits
List the most recent date first

13. Overnight hospital stays

A. _ _ _ _ _ __

A. Date in _ _ _ Date out _ __

Last Visit _ _ _ __

B. _ _ _ _ _ __

B. Date in

Date out _ _~.

Next scheduled appointment

C. _ _ _ _ _ __

C. Date in

Dateout.~~.,..;

(if any) _ _ _ __

I

,
f.

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

-6

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9

What medical conditions were treated or evaluated?

10

AF
T

0

Kind of Test
EKG (heart test)

0

0

Kind of Test
EEG (brain wave test)

Treadmill (exercise test)

0

HIVTest

.0 Cardiac Catheterization
0 Biopsy (list body part)

0

Blood Test (not HIV)

0

X-Ray (list body part)

0

MRIICT Scan (list body part)

0

Other (please describe)

R

Dates of Tests

Hearing Test

0

Speech/Language Test

0

Vision Test

0

Breathing Test

D

0

I

Dates of Tests

;,

'.

.
.• "

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 9.

FORM SSA 454-BK Paper v 18 06/09/09

I
•

Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or has
scheduled you to take. Please give the dates for past and future tests. If you need to list more tests, use Section
11 - Remarks on the last page.
.
• 0 Check this box if no tests by this provider or at this facility.

:
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5. F
us
may have medical records covering the last 12 months about any of your physical or mental
condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you
have one scheduled.
Name of Facility or Office
Name of healthcare professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
_"_ _'_.n....'_ _....._ _·....··
.............-. ­
.... .."."--------......
..... .. ...,..•. ..... ..·······r·.....··...·····----··
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Patient 10# (if known)
: P~~ne N~~be~ __ .........
rMailing Address
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I City
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.......

i Country (if not USA)
I

1
1

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Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient visits
First Visit

2. Emergency Room visits
List the most recent date first
A.

Last Visit
Next scheduled appointment

3. Overnight hospital stays
A. Date in

Date out

B.

B. Date in

Date out

C.

C. Date in

Date

};'-."

(if any)

..

What medical conditions were treated or evaluated?

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9

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,

;

10

-6

What treatment did you receive for the above condition~? (Do not describe medicines or tests in this-box.).•.c

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T

Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or has .\
scheduled you to take. Please give the dates for past and future tests. If you need to list more tests,useSectiopi
11 - Remarks on the last page.
0 Check this box if no tests by this provider or at this facility.

0

Kind of Test
EEG (brain wave test)

Treadmill (exercise test)

0

HIVTest

.0 Cardiac Catheterization

0

Blood Test (not HIV)

iD Biopsy (list body part)

0

X-Ray (list body part)

0

MRIICT Scan (list body part)

0

Other (please describe)

iD

Kind of Test
EKG (heart test)

I

Dates of Tests

R

0

Hearing Test

0

Speech/Language Test

0

Vision Test

0

Breathing Test

D

0

Dates of Tests

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 9.

FORM SSA 454-BK Paper v 18 06/09/09

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us
may have medical records covering the last 12 months about any of your physical or mental
condition(s) (including emotional or learning problems) that. This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. TeU us about your next
appointment, if you have one scheduled.
Name of healthcare professional who treated you
1 Name of Facility or Office

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARD PROVIDER ABOVE.
Phone Number
i ••.• m.
,

IVldlllll~

ID# (if known)

i

MUUI t::l>l>

-State/Province ! ZIP/PostalCode

City

! Country (if not USA)

i

Dates of Treatment (within the last 12 months)

3. Overnight hospital stays

First Visit _ _ _ __

2. Emergency Room visits
List the most recent date first

A. _ _ _ _ _ __

A. Date in ___ Date out ~""""""_

Last Visit _ _ _ __

B. _ _ _ _ _ __

B. Date in

Next scheduled appointment

C. _ _ _ _ _ __

1. Office, Clinic or Outpatient visits

I

•

(if any) _ _ _ __

Date out _ _~

, ..

C. Date in ___ Date out", . . . __ .•.....•••
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What medical conditions were treated or evaluated?

. !

I

10

-6

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

AF
T

Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or has
scheduled you to take. Please give the dates for past and future tests. If you need to list more tests, use Section.
11 - Remarks on the last page.

D Check this box If no tests by this provider or at this facility.

Kind of Test
EKG (heart test)

Dates of Tests

D

Kind of Test
EEG (brain wave test)

D
Treadmill (exercise test)

o

HIVTest

D
Cardiac Catheterization

D Blood Test (not HIV)

0

Dates of Tests'

Biopsy (list body part)

D

D Hearing Test

R

•D

D

MRIICT Scan (list body part)

D

Other (please describe)

D Speech/Language Test
0

Vision Test

0

Breathing Test
If you have been treated by more than five doctors or hospitals, use Section 11 - Remarks

on the last page and give the same detailed information as above for each healthcare provider.

FORM SSA 454-BK Paper v 18 06/09/09

If you are UNDER AGE 18, skip to Section 12 - Additional Information

nn,,,,,.r'''''' or mental condition(s) (including emotional
and learning problems) covering the last 12 months, or are you scheduled to see anyone else? (This may
include places such as workers' compensation, vocational rehabilitation, insurance companies who have paid you
disability benefits, prisons, attorneys, social service agencies and welfare.)

o

Yes (Please complete information below.)

o

No (Go to Section 7)
Phone Number

Name of
Mailing Address

I City

ZIP/Postal Code

Country (if not USA)

I

Name of Contact Person

I Date First Contact (in last 12 months)

: Date Next Contact (if any)

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9

"BreaKf.ast.

. . . . -..- . . . . ------.. . . . .

-----~."-"""~

. . . . . .­

I 10. B Do you use an assistive device (for example: eye glasses, hearing aids, braces, canes, crutch(es), walker,
I wheelchair, service animal)?
0 Always

0 Sometimes

0 Never

AF
T

I

lAYS or SOMETIMES, please describe what kind, when, and how you use it.

""1

If you need more space, use Section 11 - Remarks on the last page

R

L

J

D

C Do you have hobbies or interests?

DYes

..

'

0 No

If YES, please describe what they are and how much time you spend doing them.

~--------"If you need more space, use Section 11 - Remarks on the last page

FORM SSA 454-BK Paper v 18 06/09/09

.

-10 ­

DVes

DNo

DVes

DNo

DVes

DNo

Taking medicines

DVes

DNo

Preparing meals

DVes

D No

Feeding self

DVes

D No

DOing Chores
(inside/outside house)

DVes

DNo

Driving or using
public transportation

Dv

..............."."",,.............. ,,'"

DNo

DVes

Walking

DVes

DNo

Standing

DVes

DNo

Objects

DVes

D

arms

DVes

Sitting

D

DVes

D No

D Ves

DNo

R

Seeing. hearing.
or speaking
Concentrating

DVes

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Using hands or fingers

10

Managing money

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9

DVes

-6

hopping

D No

Remembering

DVes

D No

Understanding or
following directions

D Ves

DNo

Completing tasks

D Ves

DNo

Getting along with people

DVes

DNo

D

DVes

FORM SSA 454-BK Paper v 18 06/09/09

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9

Please write any additional information you did not give in earlier parts
is report. If you did not have enough
space in the sections of this report to write the requested information, please use this space to tell us the
additional information
in those sections. Be sure to show the section to which
are raTarr.nn

1__.1__­

Date Report Completed
(Month)

FORM SSA 454-BK Paper v 18 06/09/09

(Day)

(Year)