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HA-67 with Medical Source Information - electronic submission
Request for Evidence from Doctor or Hospital
HA-66 & HA-67 - Internet Screen
HA-67 with Medical Source Information - electronic submission
OMB: 0960-0722
OMB.report
SSA
OMB 0960-0722
ICR 201402-0960-004
IC 195762
HA-67 with Medical Source Information - electronic submission
( )
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0722 can be found here:
2020-11-06 - Revision of a currently approved collection
2017-07-11 - Revision of a currently approved collection
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application/pdf
File Title
Full page photo
Author
177717
File Modified
2014-05-01
File Created
2011-03-03
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