Form SSA-392-SUP Medical Consultant's Review of Mental Residual Functiona

See revised Privacy Act and Paperwork
Reduction Act Statments below.

SSA-392-SUP
(Medical Consultant’s Review of Residual Functional Capacity Assessment)

PRIVACY ACT NOTICE
Collection and Use of Personal Information
Sections 223 and 1633 of the Social Security Act, as amended, authorize us to collect the
information requested on this form. The information you provide will be used to make a
decision on your claim. 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 Social Security benefits. However, in accordance with 5
U.S.C. § 552a(b) of the Privacy Act, 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 an agency or third party to assist Social Security in establishing rights
to Social Security benefits and/or coverage;
2. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level;
3. To comply with Federal laws requiring the disclosure of the information from our
records; and,
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of SSA programs.
We may also use the information you provide when we match records by computer.
Computer matching programs compare our records with those of 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 other Social
Security programs are available from our Internet website at www.socialsecurity.gov or
at your local Social Security office.

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 12
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.