SSA-455-OCR-SM Disability Update Report (scannable version)

Form SSA-455-OCR-SM (XX-XXXX)
Social Security Administration

Page 1 of 7
Form Approved
OMB No. 0960-0511

Social Security Administration Disability Update Report
Information and Completion Instructions
Why We Are The Social Security Administration must regularly review the cases of people getting disability benefits
to make sure they are still disabled under our rules. It is time for us to review this case. Enclosed is a
Writing
To You Now Disability Update Report for you to answer to update us about you (or the person for whom you are the
representative payee), your health and medical conditions, any recent work activity, or any recent
training.

What To Do
First

Please read the following information, and the instructions for completing the report form, before you
answer the questions.

When To
Respond

Please complete the report, sign it and send it to us in the enclosed envelope within 30 days. If there is
no return envelope with the report, please send the signed report to us at:
Social Security Administration
P.O. Box 4550
Wilkes-Barre, PA 18767-4550

What We Do We consider the information you give us together with the information in your claim record to decide if
we need to do a full medical review. After we receive the completed report, we will notify you whether or
With
not we need to do a full medical review.
Your
Answers
If You Need
To
Contact Us

If you need to contact us, please call us toll-free at 1-800-772-1213 or TTY for the hearing impaired at
1-800-325-0778. We can answer most questions over the telephone. If you prefer to visit or call one of
our offices, please use the 800 number to get the local office address and telephone number. Please
have the Disability Update Report with you if you call or visit an office. It will help us answer your
questions. Also, if you plan to visit an office, you should call ahead to make an appointment. This wil l
help us serve you.

Sometimes, we may need more information from you. If so, we will try to call you. If you do not have a
We May
telephone, please give us a number where we can leave a message for you. Please print the telephone
Need To
Contact You number in the section provided on the back of the report form.

If We Don’t
Hear
From You

If you do not complete and return the report promptly, or tell us why you cannot respond, we may stop
sending payments to you. If it is necessary to stop your payments, we will send you another letter telling
you what we plan to do.

Form SSA-455-OCR-SM (10-2017)
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If we decide to do a full medical review of your case, you can give us any information which you believe
If We Do A
Full Medical shows that you are still disabled such as medical reports and letters from your doctors about your
health. Then, we look at all your information in your case, including the new information you give us,
Review
and decide whether you continue to be disabled under our rules.

Appeals And When we review your case, we may find that you are no longer disabled under our rules, and your
payments may stop. If your payments stop, you can appeal our decision or you can ask us to continue
Continued
to make payments while you appeal.
Benefits
If You Want
To Work

Do you want to work, but worry about losing your payments or Medicare before you can support
yourself? We want to help you go to work when you are ready. But, work and earnings may affect your
benefits. Your local Social Security office can tell you more about work incentives, and how work and
earnings can affect your benefits.

Privacy Act Statement Collection and Use of Personal Information
The Privacy
And
Paperwork Sections 205(a), 221(i), 223(d), 1614(a)(4), 1631(e)(1), and 1633(a) and (c) of the Social Security Act,
as amended, allow us to collect this information. Furnishing us this information is voluntary. However,
Reduction
failing to provide all or part of the information may prevent us from making an accurate and timely
Acts
decision on any claim filed.
We will use the information to make a determination of continued eligibility for benefits. We may also
share your information for the following purposes, called routine uses:
1. To private medical and vocational consultants for use in making preparation for, or evaluating the
results of, consultative medical examinations or vocational assessments which they were engaged to
perform by the Social Security Administration (SSA) ora State agency acting in accord with sections
221 or 1633 of the Act; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the
efficient administration of its programs. We contemplate disclosing information under this routine use
only in situations in which SSA may enter a contractual agreement with a third party to assist in
accomplishing an agency function relating to this system of records.
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 Notice (SORN)
60-0089, entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are
available on our website at www.socialsecurity.gov/foia/bluebook.
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. The OMB control number for this collection is 0960-0511. We estimate that it will take 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.

Form SSA-455-OCR-SM (10-2017)

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GENERAL
The Disability Update Report is a scannable form which can be “read” electronically. To help us
INSTRUCTIONS process your report, please follow these instructions when you answer the questions on the
report form:
- HOW TO
COMPLETE
“SCANNABLE” 1. USE BLACK INK OR A #2 PENCIL.
FORMS
2. KEEP YOUR NUMBERS, LETTERS, AND “X’S” INSIDE THE BOXES.
3. NUMBERS: Try to make your numbers look like these:

4. LETTERS: Print in CAPITALS. Try to make your letters look like these:

5. MONEY AMOUNTS: Show dollars only. Do not use dollar signs ($), and do not show cents. For
example, show $1,540.30 like this:
Dollars Only, No Cents

6. DATES: Put a number in each box. For example, show September 9, 2003, like this:
Month
Year

7. THE REPORT PERIOD: The “report period” is the period of time for which we need information. It is
described at the top of the report form to the right of your name, and again in questions 1 through 6.
Usually, the report period is the last 24 months, but it may be less. It is important that you keep the
report period in mind when answering the questions.
HOW TO FILL OUT THE REPORT FORM
QUESTION 1.a. If you have not worked during the report period, place an “X” in the box below “NO”, and go on to
- Have You
question 2. If you have worked, mark the box below “YES”, and answer question l.b.
Worked?

QUESTION 1.b.
- When You
Worked And
Your Monthly
Earnings

Describe your most recent work activity first. Print the months and years you began and ended
working in the boxes under “Work Began” and “Work Ended.” If you are working now, print the current
month and year in the first set of boxes under “Work Ended.” Print your gross monthly earnings for the
periods you worked in the boxes.

QUESTION 2 - Place an “X” in the box below “YES” if you have attended school and/or a training program during the
School Or Work report period; otherwise, mark the box below “NO”. This could include high school equivalency
Training
programs, college courses, vocational evaluation or retraining programs, but
generally would not include group therapy or hobbies.

Form SSA-455-OCR-SM (10-2017)

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QUESTION 3 - Tell us if you have discussed with your doctor whether you can return to any kind of work, and if so,
Can You Work? whether the doctor told you that you can return to work, even if the work permitted is less physically
demanding and/or less stressful than your usual work. Place an “X” in only 1 box.
QUESTION 4 How Is Your
Health?

We want to know how your overall health now compares to what it was at the beginning of the report
period. You may feel that your health has gotten worse, has improved, or you may feel that your health
is about the same and has not gotten better or worse. Place an “X” in only 1 box.

QUESTION 5 - A “doctor or clinic” can include treatment such as evaluations, checkups, counseling, providing
Treatment By A prescriptions or medicine by a doctor, visiting nurse, family health center, psychologist, licensed
Doctor Or Clinic counseling service, physical therapist, a chiropractor or other licensed health provider.
Treatment may be provided in person or by telephone or other contact.
How To Answer If you have not been treated by a doctor or clinic during the report period, place an “X” in the box below
Question 5.a.
“NO”, and go on to question 6. If you have gone to a doctor or clinic during the report period, mark the
box below ‘’YES”, and answer question 5.b.
Question 5.b. Reason For
The Visit

Please start with the most recent visit and then work backwards in time. Print as much information as
will fit, but keep a space between each word. Try to use the most important or key word(s), such as
ARTHRITIS or BAD BACK, or HYPERTENSION or HIGH BLOOD. Your medical bills or doctor can
provide a short, accurate description.

Date of Visit

Print the month and year you were treated. Complete all 4 boxes. For example, print September 10,
2003, as 09 03.
NOTE: If needed, use the “REMARKS” section on side 2 of the form.

QUESTION 6.a - Place an “X” in the box below “NO” if you have not been hospitalized or not had surgery during the
Have You Been report period. If you have been hospitalized or had surgery during the report period, then place an “X”
Hospitalized Or in the box below ‘’YES” and answer question 6.b.
Had Surgery?
Question 6.b. Reason For
Treatment

Please report your most recent treatment first and then work backwards in time. Try to provide the most
important information. Keep a space between each word. Your medical bills or doctor can
provide short, accurate words.

Date of
Treatment

Print the month and year you were hospitalized or had surgery. Be sure to use all four spaces. If you
were hospitalized more than one month, print last month you were hospitalized.
NOTE: If needed, use the “REMARKS” section on side 2 of the form.

Remarks
Section

If you need more room to answer questions l.b., 5.b. and/or 6.b., or there are any other facts or
statements you want us to consider, place an “X” in the box and write in this section. If necessary, use
an extra piece of paper.

Date and
Telephone
Sections

Please date the report form. Please provide a telephone number where you can be reached during the
day.

Form SSA-455-OCR-SM (10-2017)

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Form Approved
OMB No. 0960-0511

DATE:

Social Security Administration P.O. Box

, Wilkes-Barre. PA 18767-

Disability Update Report
REPORT PERIOD

PAYEE'S NAME AND ADDRESS

To The Present

From:
BENEFICARY
TELEPHONE NUMBER BNC #

PSC:

Please be sure to use black ink or a #2 pencil to print your answers. Also, read the enclosed instructions before
completing the form. Finally, remember that when answering the questions, the “REPORT PERIOD” for which we need
information about you is from
to the present. If you have any questions, call 1-800-772-1213 or TTY for
the hearing impaired at 1-800-325-0778.
1. a. Since

have you worked for someone or been self-employed?

YES

NO

b. If you answered "YES" to 1.a., Please complete the information below.
Most
Recent
Work

WORK BEGAN

WORK ENDED

MONTHY EARNINGS

Month

Month

Dollars Only, No Cents

Year

Year
$

1.

$

2.

$

3.

2. Have you attended any school or work training program(s) since

?

YES

NO

to the present...(Please place an ‘X’ in one box only):

3. Since
my doctor and I
have not discussed
whether I can work.

my doctor told me I
cannot work.

my doctor told me I
can work.

4. Place an “X” in only one box which best describes your health now as compared to
BETT

ER

Form SSA-455-OCR-SM (10-2017)
SAME

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Form SSA-455-OCR-SM (10-2017)

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FOR SSA USE ONLY
BNC #
AC?

5. a. Have you gone to a doctor or clinic for treatment (including evaluations, checkups, counseling,
prescriptions, or medicine) since
?

YES

NO

b. If you answered “YES” to 5.a., please list:
Reason For Visit:
Most
Recent
Visit

Month

Year

1.
2.
3.

6 a. Have you been hospitalized or had surgery since

?

YES

NO

b. If you answered “YES” to 6.a., please list:
Reason For Hospitalization or Surgery:
Most
Recent

Month

Year

1.
2.
3.

REMARKS: If you use this space to further answer questions 1. through 6., place an “X” in the box to the right and
print on the lines below.

SIGN
HERE
DATE REPORT
COMPLETED (MM/DD/YYYY)

TODAY'S DATE

TELEPHONE NUMBER (include Area Code)