Form HA-67 Request for Medical Evidence From a Hospital

SOCIAL SECURITY ADMINISTRATION
Refer To:
Claimant Social Security Number
Claimant Name
DOB

Office of Disability Adjudication and Review
Hearing Office Name
Hearing Office Street Address
City, State Zip Code
Telephone Number/Fax Number
Month Day, Year

Hospital Name
Hospital Street Address
City, State Zip Code

A claim for disability benefits, filed by the above-named individual under the Social Security
Act, is before the Office of Disability Adjudication and Review for hearing and decision.
Please provide the following information within the next ten days:
Requested information
If you are currently registered as a user of the Electronic Records Express (ERE), use the
attached barcode information when submitting the requested evidence (RQID, RF, and DR
fields). If you are not a registered user of ERE, fax the evidence, along with the enclosed
barcode, using this fax number– (877)548-8804. Remember that the enclosed barcode must be
the first page of each set of documents being faxed. Note: If you request payment, the request
should be returned to the address shown above or sent via the fax number noted below – it
is different than the FECS fax number used for medical evidence.
Your assistance in furnishing this information will facilitate the adjudication of this claim and
will be greatly appreciated. A medical release form is enclosed. We are authorized to pay up to
$ , which is the same amount that the Disability Determination Service Office pays for such a
report. If you require payment for the evidence, please supply us with the necessary information
requested on the attached page and return this letter by mail or fax (Hearing Office Fax Number)
to our office as soon as possible. If you have any questions, please contact (Contact Person) at
the phone number listed above.
Thank you for your cooperation.

Sincerely,

ALJ Name
Administrative Law Judge
Enclosures

Form HA-L67 (03-2007)

See Next Page

Claimant Name (Claimant Social Security Number)

Page 2 of 2

Hospital Name
Hospital Street Address
City, State Zip Code
Medical Source Information (to be completed by physician)
Signature:

Amount:

SSN or, if incorporated, EIN:

Date:

Remittance Address:
Telephone Number:
Hearing Office Information (to be completed by hearing office personnel)
Evidence Received by:
CAN:
TPD#

SOC:

Date:
APPROVED FOR PAYMENT BY:

PAID BY (INITIALS)

DATE:

SYSTEMS ID NUMBER

DATE:

Form HA-L67 (03-2007)

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INSERT THIS END FIRST

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Please include this barcode cover sheet as the first page
of each set of documents returned.

Fax the evidence to this fax number:
(877)548-8804

Claimant: Claimant Name
SSN: Claimant Social Security Number

SSA will insert the following revised Privacy Act and PRA Statements into the form at
its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act as amended, [42
U.S.C. 405(a), 1383(d)(1) and 1383(e)(1)] authorize us to collect this information. We
will use the information you provide to help us determine the amount of this claim. The
information you provide on this form is voluntary. However, failure to provide the
requested information may prevent us from making an accurate and timely decision on
any claim filed.
We rarely use the information you provide on this form for any 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 or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records to other agencies (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 local level.
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 agencies 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.
A complete list of routine uses for this information is available in our System of Records
Notices entitled, Administrative Law Judge Working File on Claimant Cases, 60-0005
and Claims Folders Systems, 60-0089. The notices, additional information regarding
this form, and information regarding our system and programs, are available on-line at
www.socialsecurity.gov or at any 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 15
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.