HA-4632 Claimant's Medications

SOCIAL SECURITY ADMINISTRATION

CLAIMANT'S MEDICATIONS

A. To be completed by Hearing Office
(Claimant and Social Security Number)

B. To be completed by the claimant

Form Approved
OMB No.0960-0289

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

PLEASE PRINT

PLEASE LIST BELOW THE PRESCRIPTION MEDICATION WHICH YOU ARE PRESENTLY TAKING. IF THE
NAME OF THE MEDICATION IS NOT SHOWN ON THE PRESCRIPTION CONTAINER, YOU MAY VERIFY THE
NAME WITH YOUR PHARMACIST.
NAME OF
DATE FIRST
DAILY
REASONS FOR MEDICATION
NAME OF
MEDICATION & PRESCRIBED
AMOUNT
PHYSICIAN
DOSAGE
TAKEN

PLEASE LIST BELOW THE NONPRESCRIPTION MEDICATION YOU ARE TAKING AND THE REASONS YOU TAKE THEM.

Form HA-4632 (2-1994) ef (10-2012)
Use Until Stock Is Exhausted

If more space is needed,
use additional sheets.

Privacy Act Statement
Collection and Use of Personal Information
Sections 205, 223, 702, 1614, 1631, and 1869 of the Social Security Act, as amended allow us to
collect this information. Furnishing us this information is voluntary. However, failing to provide all
or part of the information may prevent us from re-evaluating the decision on your claim.
We will use the information to determine your eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
1. To representative payees, when the information pertains to individuals for whom they serve
as representative payees, for the purpose of assisting the Social Security Administration in
administering its representative payment responsibilities under the Act and assisting the
representative payees in performing their duties as payees, including receiving and accounting for
benefits for individuals for whom they serve as payees; and
2. To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representatives or representative payees to the extent necessary to pursue Social
Security claims and to representative payees when the information pertains to individuals for
whom they serve as representative payees, for the purpose of assisting SSA in administering its
representative payment responsibilities under the Act and assisting the representative payees in
performing their duties as payees, including receiving and accounting for benefits for individuals
for whom they serve as payees.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts
under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN)
60-0089, entitled Claims Folders System and 60-0103, entitled Supplemental Security Income
Record and Special Veterans Benefits. Additional information and a full listing of all our SORNs
are available on our website at www.ssa.gov/privacy.
See Revised PRA Statement Attached

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. 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-4632 (2-1994) ef (10-2012)

SSA will insert the following revised PRA Statement into the form as soon as possible:
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 (OMB) 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 regarding this burden estimate or any other aspect of this collection,
including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.