Form SSA-199 Vocational Rehabilitation Provider Claim

FORM APPROVED

SOCIAL SECURITY ADMINISTRATION

VOCATIONAL REHABILITATION PROVIDER CLAIM
PRIVACY ACT STATEMENT: The authority to access inform ation from vocational rehabilitation providers on titles II
and XVI beneficiaries is contained in section 205Ia) and 1633la) of the Social Security Act, Completion of this
form is voluntary, however, no payment can be made unless required claims information is made available to the
Social Securlty Administration using this form or another mutually agreed upon method for submitting a claim. SSA
will use the information provided on this form to make claim determinations.

PAPERWORK REDUCTION ACT STATEMENT: f his information collection meets the clearance requirements of 44
U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1896. You are not required to answer
these questions unless we display a valid Office of Management and Budget control number. We estimate that it
will take you about 23 minutes to read the instructions, gather the necessary facts, and answer the questions.

From:

To:

Social Security Administration
Office of Employment Support Programs
Division of Employment Support and Program Aquisitions
P.O.Box 17714
Baltimore, Maryland 2 1235-7714

VR Provider
Code

Check One

Claim Based On:

continuous Period of SGA

~ e d i e a Recovery
l
during VR

1f claim is based upon other than a continuous period of SGA, it is not necessary t o complete items 6, 8, 4, or 13 below.
7 , Client {First Name, MI, Last Name)

SSA
SSI

2.

3.SSN (Widow or child. if bppropriats)

'SSN (Primary)

5a. Date Client Enrered 6b, Date Signed IPE
VR 00

4.

Non-Blind
6 . Date Employment Began

7 . Date of Final VR
Closure

8. Months Work Activity Tracked After VR
Closing (show months)

9. Medical services were provided, initiated, or coordinated under IWRP

10. Claim based solely on extended evaluation services (VR 06)

.

1 1 Direct cost during VR (after 9130181)

-- Total from Item 17d (over)

8

12. Administrative, counseling and placement costs during VR (after 9/30181)

$

1 3. Administrative costs onlv for tracking after VR (after 913018 1 1

8

14. Other (identify)

S

15. Total amount chimed

$

Remarks:

Signature

l~itle

1 ate
I

Form SSA-I 99 (2-2002) EF (2-2002)
Destroy prior editions

CONTINUED ON REVERSE SIDE

w

16.What type

of occupation(s) did the client perform during the continuous period of SGA:

17. Itemization of direct cost services provided during the period of VR (after 91301811:
(Use additional sheets as needed)

17a.

17b.

Ilc,

Date of Service

Type of Service

Cost of Service

#1
#2

#3
#4

#5

#6
#7

#8
#9
#10
fll

#I 2
#13

#14
#15

#I 6
#I
7
#I8

#I 9
#20

17d. Total of column 17c (also enter in item 1 1

-

over)

$

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