Form HA-4632 Claimant's Medications

Form Approved
OMB No.0960-0289

SOCIAL SECURITY ADMINISTRATION
Office of Disability Adjudication and Review

CLAIMANT'S MEDICATIONS
A. To be completed by Hearing Office
(Claimant and Social Security Number)

(Wage Earner and Social Security Number) The last time we brought your case
(Leave blank if same as claimant)
up-to-date was:

B. 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
DATE FIRST
DAILY
REASONS FOR MEDICATION
NAME OF
MEDICATION & PRESCRIBED
AMOUNT
PHYSICIAN
DOSAGE
TAKEN

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

Form HA-4632 (2-1994) ef (6-2009)
Use Until Stock Is Exhausted

If more space is needed,
use additional sheets.

Privacy Act Statement
Collection and Use of Personal Information

See Revised 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 60-0089.
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.
See Paperwork
Paperwork Reduction Act Statement - This information collection
meets theAct
requirements
of 44
Reduction
Statement
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. 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.
Form HA-4632 (2-1994) ef (6-2009)

SSA will insert the following revised PRA Statement into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (C) of the Social Security Act,
as amended, authorize us to collect this information. We will use the information you provide to
determine your potential eligibility for benefit payments and to help us to decide if we need
additional information.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making an accurate and timely decision on any claim filed, or
could result in the loss of benefits.
We rarely use the information you supply for any purpose other than to determine entitlement to
benefit payments. 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 facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
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.
A complete list of routine uses for this information is available in Systems of Records Notice
entitled, Claims Folders Systems, 60-0089. This 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.

SSA will insert the following revised PRA Statement 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 (OMB) control number. The OMB control number for this
collection is 0960-0289. We estimate that it will take about 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.