Form SSA-199 Vocational Rehabilitation Provider Claim

FORM APPROVED
OMB No. 0960-0310

SOCIAL SECURITY ADMINISTRATION

VOCATIONAL REHABILITATION PROVIDER CLAIM
PRIVACY ACT STATEMENT: The authority to access information from vocational rehabilitation providers on titles II
and XVI beneficiaries is contained in section 205(a) and 1633(a) 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 Security 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: This information collection meets the clearance requirements of 44
U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. 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.

See revised Paperwork Reduction Act and Privacy Act Statements below.
To:

From:
Social Security Administration
Office of Employment Support Programs
Replace with the following
Division of Employment Support and Program Aquisitions
Operations Team
P.O. Box 17714
Baltimore, Maryland 21235-7714

text: VRA

VR Provider
Code

Check One

Claim Based On:

Continuous Period of SGA

Medical Recovery during VR

If claim is based upon other than a continuous period of SGA, it is not necessary to complete items 6, 8, 9, or 13 below.
1. Client (First Name, MI, Last Name)

2.

SSA

3. SSN (Widow or child, if appropriate) 4.

SSN (Primary)

Blind

SSI
5a. Date Client Entered 5b. Date Signed IPE
VR OO

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

Yes

No

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

Yes

No

11. Direct cost during VR (after 9/30/81) -- Total from Item 17d (over)

$

12. Administrative, counseling and placement costs during VR (after 9/30/81)

$

13. Administrative costs only for tracking after VR (after 9/30/81)

$

14. Other (identify)

$

15. Total amount claimed

$

Remarks:

Directly below this line of highlighted text insert the following text with check boxes: "Check One: Initial
Claim ____ Reconsideration_____Resubmittal_____Supplemental____"

Signature

Title

Form SSA-199 (2-2002) EF (2-2002)
Destroy prior editions

CONTINUED ON REVERSE SIDE

Date

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 9/30/81):
(Use additional sheets as needed)
17a.

17c.

17b.
Date of Service

Type of Service

Cost of Service

#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#11
#12
#13
#14
#15
#16
#17
#18
#19
#20
17d. Total of column 17c (also enter in item 11 - over)

Add the following website address:
www.socialsecurity.gov/work

$

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 2 hours
and 53 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 1-800325-0778). 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.

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a) and 1633(a) of the Social Security Act authorize us to collect this
information. The information you provide us on this form will be used to make claim
determinations.
Completion of this form is voluntary, however, we cannot make a payment unless you
make the required claims information available to us using this form or another mutually
agreed upon method for submitting a claim.
We rarely use this information you supply for any purpose other than for deciding on a
claim. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency 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 Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and
4. To audit or investigate 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 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 our
programs and systems, is available on-line at www.socialsecurity.gov or at your local
Social Security office.