Form HA-4632 Claimant's Medications

SOCIAL SECURITY ADMINISTRATION
Office of Hearings and Appeals

Form Approved
OMB No. 0960-0289

CLAIMANT'S MEDICATIONS
A.

To be completed by Hearing Office

(Claimant and Social Security Number)

B.

(Wage Earner and Social Security Number)
(Leave blank if same as claimant)

-

-

The last time we brought
your case up-to-date was:

-

To be completed by the claimant

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
MEDICATION &
DOSAGE

DATE FIRST
PRESCRIBED

DAILY AMOUNT
TAKEN

REASON FOR MEDICATION

NAME OF
PHYSICIAN

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

FORM HA-4632 (2-1994) ef (10-2004)
Use Until Stock Is Exhausted

If more space is needed,
use additional sheets.

See revised Privacy Act and Paperwork Reduction Act
Statements below.
PRIVACY ACT AND PAPERWORK ACT NOTICE
The Social Security Act (sections 205(a), 702, 1631 (e)(1)(A) and (B), and 1869(b)(1) and (C),
as appropriate) authorizes the collection of information on this form. We will use the
information on your work background to help us decide if we need to obtain more information.
You do not have to give it, but if you do not you may not receive benefits under the Social
Security Act. We may give out the information on this form without your written consent, if we
need to get more information to decide if you are eligible for benefits or if a Federal law
requires us to do so. Specifically, we may provide information to another Federal, State, or local
government agency which is deciding your eligibility for a government benefit or program; to
the President or Congressman inquiring on your behalf; to an independent party who needs
statistical information for a research paper or audit report on a Social Security program; or to the
Department of Justice to represent the Federal Government in a court suit related to a program
administered by the Social Security Administration.
We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government agencies.
Many agencies may use matching programs to find or prove that a person qualifies for benefits
paid by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security Offices. If you want to learn more about this, contact
any 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. You may send comments on our time estimate above to:
SSA, 1338 Annex Building, 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 (10-2004)

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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.

PRIVACY ACT STATEMENT
The Social Security Act (sections 205(a), 702, 1631 (e)(1)(A) and (B), and 1869(b)(1) and (C),
as appropriate) authorizes the collection of information on this form. The information you provide
will help us to determine your potential eligibility for benefit payments and to help us to decide if
additional information is needed. Your response is voluntary. However, failure to provide the
requested information may prevent an accurate and timely decision on any claim filed, or could
result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for determining
entitlement to benefit payments. In accordance with 5 U.S.C.§ 552a(b) of the Privacy Act,
however, we may disclose the information provided on this form 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 Veteran’s 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 and 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 System of Record Notice 600089. The notice, additional information regarding this form, and information regarding our
programs and systems are available on-line at www.socialsecurity.gov or at your local Social
Security office.