Form HA-4631 CLAIMANT'S RECENT MEDICAL TREATMENT

Social Security Administration

Form Approved
OMB No.0960-0292

Office of Disability Adjudication and Review

CLAIMANT’S RECENT MEDICAL TREATMENT
A. To be completed by hearing office
(Claimant and Social Security Number)

(Wage Earner and Social Security Number) The last time we brought your
(Leave blank if same as claimant)
case up-to-date was:

B. To be completed by 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?

Yes

No

(If yes, please list the name, addresses and telephone numbers of doctors who have treated or examined you since the
above date. Also list dates of treatment or examination. If possible, send updated reports from these doctors to the
Administrative Law Judge prior to 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?
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 (8-1996) ef (6-2009)
Issue 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.
See revised
The information you furnish on this form is voluntary.
However,
Privacy
Act failure to provide the requested
information may prevent you from receiving benefits
under the below.
Social Security Act.
Statement
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.socialsecurity.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. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed
form.
Form HA-4631 (8-1996) ef (6-2009)

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
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. We will use the information you provide to
determine whether we need additional information regarding your treatments or conditions.
The information you provide on this form is voluntary. However, failing to provide this
information may prevent you from receiving benefits under the Social Security Act.
We generally use the information you supply to determine 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.
A complete list of routine uses for this information is available in our System of Records Notice
entitled, Claims Folders Systems, 60-0089. This notice, additional information regarding this
form, and information regarding our programs and systems, are available on-line at
http://www.socialsecurity.gov or at your local Social Security office.