Current Version - SSA-455

SSA-455 - Current.pdf

Disability Update Report

Current Version - SSA-455

OMB: 0960-0511

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QUESTION 3 Can You Work?

Tell us if you have discussed with your doctor whether you can return
to any kind of work, and if so, whether the doctor told you that you can
return to work, even if the work permitted is less physically demanding
and/or less stressful than your usual work. Place an “X” in only 1 box.

QUESTION 4 How Is Your
Health?

We want to know how your overall health now compares to what it was
at the beginning of the report period. You may feel that your health has
gotten worse, has improved, or you may feel that your health is about the
same and has not gotten better or worse. Place an “X” in only 1 box.

QUESTION 5 Treatment By A
Doctor Or Clinic

A “doctor or clinic” can include treatment such as evaluations, checkups,
counseling, providing prescriptions or medicine by a doctor, visiting
nurse, family health center, psychologist, licensed counseling service,
physical therapist, a chiropractor or other licensed health provider.
Treatment may be provided in person or by telephone or other contact.

How To Answer
Question 5.a.

If you have not been treated by a doctor or clinic during the report
period, place an “X” in the box below “NO”, and go on to question 6. If
you have gone to a doctor or clinic during the report period, mark the
box below ‘’YES”, and answer question 5.b.

Question 5.b. Reason For
The Visit

Please start with the most recent visit and then work backwards
in time. Print as much information as will fit, but keep a space between
each word. Try to use the most important or key word(s), such as
ARTHRITIS or BAD BACK, or HYPERTENSION or HIGH BLOOD.
Your medical bills or doctor can provide a short, accurate description.

Date of Visit

Print the month and year you were treated. Complete all 4 boxes. For
example, print September 10, 2003, as 09 03.

NOTE: If needed, use the “REMARKS” section on side 2 of the form.

Social Security Administration
Disability Update Report
Information and Completion Instructions
Why We Are
Writing To
You Now

The Social Security Administration must regularly review the cases of
people getting disability benefits to make sure they are still disabled
under our rules. It is time for us to review this case. Enclosed is a
Disability Update Report for you to answer to update us about
you (or the person for whom you are the representative payee), your
health and medical conditions, any recent work activity, or any recent
training.

What To
Do First

Please read the following information, and the instructions for
completing the report form, before you answer the questions.

When to
Respond

Please complete the report, sign it and send it to us in the enclosed
envelope within 30 days. If there is no return envelope with the report,
please send the signed report to us at:
Social Security Administration
P.O. Box 4550
Wilkes-Barre, PA 18767-4550

What We Do
With Your
Answers

We consider the information you give us together with the information
in your claim record to decide if we need to do a full medical review.
After we receive the completed report, we will notify you whether or not
we need to do a full medical review.

QUESTION 6.a Have You Been
Hospitalized Or
Had Surgery?

Place an “X” in the box below “NO” if you have not been hospitalized or
not had surgery during the report period. If you have been hospitalized
or had surgery during the report period, then place an “X” in the box
below ‘’YES” and answer question 6.b.

If You Need
Help To
Answer The
Report

It is important that information you give us is accurate. We have tried
to make report questions easy to understand and answer. But, if you
find that you do not understand a question or questions, please contact
us, your authorized representative, a social service agency, your doctor
or clinic, or some other person you trust.

Question 6.b. Reason For
Treatment

Please report your most recent treatment first and then work
backwards in time. Try to provide the most important information.
Keep a space between each word. Your medical bills or doctor can
provide short, accurate words.

If You Need
To Contact
Us

Date of
Treatment

Print the month and year you were hospitalized or had surgery. Be
sure to use all four spaces. If you were hospitalized more than one
month, print last month you were hospitalized.

If you need to contact us, please call us toll-free at 1-800-772-1213
or TTY for the hearing impaired at 1-800-325-0778. We can answer
most questions over the telephone. If you prefer to visit or call one of
our offices, please use the 800 number to get the local office address
and telephone number. Please have the Disability Update Report with
you if you call or visit an office. It will help us answer your questions.
Also, if you plan to visit an office, you should call ahead to make an
appointment. This will help us serve you.

We May Need
To Contact
You

Sometimes, we may need more information from you. If so, we will try
to call you. If you do not have a telephone, please give us a number
where we can leave a message for you. Please print the telephone
number in the section provided on the back of the report form.

If We Don’t
Hear From You

If you do not complete and return the report promptly, or tell us why
you cannot respond, we may stop sending payments to you. If it is
necessary to stop your payments, we will send you another letter
telling you what we plan to do.

NOTE: If needed, use the “REMARKS” section on side 2 of the form.

Remarks
Section
Signature, Date
and Telephone
Sections
FORM SSA-455-OCR-SM (10-2014)

If you need more room to answer questions l.b., 5.b. and/or 6.b., or
there are any other facts or statements you want us to consider, place
an “X” in the box and write in this section. If necessary, use an extra
piece of paper.
Please sign the report form as you usually sign your name. Please
provide a telephone number where you can be reached during the day.
4

Printed on Recycled Paper

FORM SSA-455-OCR-SM (10-2014)

Continued on the Reverse

If We Do A
Full Medical
Review

If we decide to do a full medical review of your case, you can give us
any information which you believe shows that you are still disabled,
such as medical reports and letters from your doctors about your
health. Then, we look at all your information in your case, including the
new information you give us, and decide whether you continue to be
disabled under our rules.

Appeals And
Continued
Benefits

When we review your case, we may find that you are no longer disabled
under our rules, and your payments may stop. If your payments stop,
you can appeal our decision or you can ask us to continue to make
payments while you appeal.

If You Want
To Work

Do you want to work, but worry about losing your payments or
Medicare before you can support yourself? We want to help you go to
work when you are ready. But, work and earnings may affect your
benefits. Your local Social Security office can tell you more about work
incentives, and how work and earnings can affect your benefits.

The Privacy
And
Paperwork
Reduction
Acts

Privacy Statement Collection and Use of Personal Information – Sections
205(a) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended, and Social
Security regulations at 20 C.F.R. 404.1589 and 416.989 authorize us to collect this
information. We will use the information you provide to further document your
claim and permit a determination about continuing disability.

GENERAL
INSTRUCTIONS
- HOW TO
COMPLETE
“SCANNABLE”
FORMS

The Disability Update Report is a scannable form which can be “read”
electronically. To help us process your report, please follow these
instructions when you answer the questions on the report
form:
1. USE BLACK INK OR A #2 PENCIL.
2. KEEP YOUR NUMBERS, LETTERS, AND “X’S” INSIDE THE
BOXES.
3. NUMBERS: Try to make your numbers look like these:

0 1 2 3 4 5 6 7 8 9

4. LETTERS: Print in CAPITALS. Try to make your letters look
like these:

A B C D E F G H I J K L M
N O P Q R S T U V W X Y Z
5. MONEY AMOUNTS: Show dollars only. Do not use dollar signs
($), and do not show cents. For example, show $1,540.30 like this:
Dollars Only, No Cents

0 1 ,540

Furnishing us this information is voluntary. However, failing to provide us with all
or part of the information may prevent an accurate and timely decision on any claim
filed.

6. DATES: Put a number in each box. For example, show September
9, 2003, like this:
Month

We rarely use the information you supply us for any purpose other than for
the reasons explained above. However, we may use the information for the
administration of our programs including sharing information:

09 03

1. To comply with Federal laws requiring the release of information from our
records (e.g., to the Government Accountability Office and Department of
Veterans Affairs);

7. THE REPORT PERIOD: The “report period” is the period of
time for which we need information. It is described at the top of
the report form to the right of your name, and again in questions 1
through 6. Usually, the report period is the last 24 months, but it
may be less. It is important that you keep the report period
in mind when answering the questions.

2. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity and improvement of our programs (e.g., to the Bureau of the
Census and to private entities under contract with us).
A complete list of when we may share your information with others, called routine
uses, is available in our Privacy Act Systems of Records Notices entitled, Claims
Folders Systems (60-0089) and the Master Beneficiary Record (60-0090). Additional
information about this and other system of records notices and our programs are
available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through
computer matching programs. Matching programs compare our records with records
kept by other Federal, State or local government agencies. We use the information
from these programs to establish or verify a person’s eligibility for federally funded
or administered benefit programs and for repayment of incorrect payments or
delinquent debts under these programs.
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 0960-0511. We estimate that it will take 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.
FORM SSA-455-OCR-SM (10-2014)

Year

QUESTION 1.a. Have You
Worked?

HOW TO FILL OUT THE REPORT FORM

If you have not worked during the report period, place an “X” in the
box below “NO”, and go on to question 2. If you have worked, mark the
box below “YES”, and answer question l.b.

QUESTION 1.b. When You
Worked And
Your Monthly
Earnings

Describe your most recent work activity first. Print the months
and years you began and ended working in the boxes under “Work
Began” and “Work Ended.” If you are working now, print the
current month and year in the first set of boxes under “Work Ended.”
Print your gross monthly earnings for the periods you worked in the
boxes.

QUESTION 2 School Or Work
Training

Place an “X” in the box below “YES” if you have attended school and/or
a training program during the report period; otherwise, mark the box
below “NO”. This could include high school equivalency programs,
college courses, vocational evaluation or retraining programs, but
generally would not include group therapy or hobbies.

FORM SSA-455-OCR-SM (10-2014)

Continued on the Reverse

If We Do A
Full Medical
Review

Appeals And
Continued
Benefits

If You Want
To Work

The Privacy
And
Paperwork
Reduction
Acts

GENERAL
INSTRUCTIONS
- HOW TO
COMPLETE
“SCANNABLE”
FORMS

0 1 2 3 4 5 6 7 8 9

4. LETTERS: Print in CAPITALS. Try to make your letters look
like these:

0 1 ,540

Furnishing us this information is voluntary. However, failing to provide us with all
or part of the information may prevent an accurate and timely decision on any claim
filed.

6. DATES: Put a number in each box. For example, show September
9, 2003, like this:
Month

09 03

1. To comply with Federal laws requiring the release of information from our
records (e.g., to the Government Accountability Office and Department of
Veterans Affairs);

Year

QUESTION 1.a. Have You
Worked?

HOW TO FILL OUT THE REPORT FORM

If you have not worked during the report period, place an “X” in the
box below “NO”, and go on to question 2. If you have worked, mark the
box below “YES”, and answer question l.b.

QUESTION 1.b. When You
Worked And
Your Monthly
Earnings

QUESTION 2 School Or Work
Training

FORM SSA-455-OCR-SM (10-2014)

Continued on the Reverse

QUESTION 3 Can You Work?

QUESTION 4 How Is Your
Health?

QUESTION 5 Treatment By A
Doctor Or Clinic

How To Answer
Question 5.a.

Question 5.b. Reason For
The Visit

Date of Visit

Print the month and year you were treated. Complete all 4 boxes. For
example, print September 10, 2003, as 09 03.

NOTE: If needed, use the “REMARKS” section on side 2 of the form.

Social Security Administration
Disability Update Report
Information and Completion Instructions
Why We Are
Writing To
You Now

What To
Do First

Please read the following information, and the instructions for
completing the report form, before you answer the questions.

When to
Respond

What We Do
With Your
Answers

QUESTION 6.a Have You Been
Hospitalized Or
Had Surgery?

If You Need
Help To
Answer The
Report

Question 6.b. Reason For
Treatment

If You Need
To Contact
Us

Date of
Treatment

Print the month and year you were hospitalized or had surgery. Be
sure to use all four spaces. If you were hospitalized more than one
month, print last month you were hospitalized.

We May Need
To Contact
You

If We Don’t
Hear From You

NOTE: If needed, use the “REMARKS” section on side 2 of the form.

Remarks
Section

Signature, Date
and Telephone
Sections

Please sign the report form as you usually sign your name. Please
provide a telephone number where you can be reached during the day.

FORM SSA-455-OCR-SM (10-2014)

Printed on Recycled Paper

FORM SSA-455-OCR-SM (10-2014)

Continued on the Reverse

DATE:

Disability Update Report
Social Security Administration, P.O. Box

FORM APPROVED
OMB NO. 0960-0511

, Wilkes-Barre. PA 18767-

PAYEE’S NAME AND ADDRESS

REPORT PERIOD
From:

To The Present

BENEFICIARY
TELEPHONE NUMBER

PSC:

CLAIM NUMBER

Please be sure to use black ink or a #2 pencil to print your answers. Also, read the enclosed instructions
before completing the form. Finally, remember that when answering the questions, the “REPORT PERIOD” for
which we need information about you is from
to the present. If you have any
questions, call 1-800-772-1213 or TTY for the hearing impaired at 1-800-325-0778.

a. Since

have you worked for someone

YES

or been self-employed?
b. If you answered “YES” to 1.a., please complete the information below.
WORK BEGAN

Most
Recent
Work

2.
3.

Month

Year

WORK ENDED
Month

MONTHLY EARNINGS

Year

Dollars Only, No Cents

Have you attended any school or work training program(s)
since
?
Since

YES

to the present...(Please place an ‘X’ in one box only):
my doctor and I
have not discussed
whether I can work.

my doctor
told me I
cannot work.

my doctor
told me I
can work.

Place an “X” in only one box which best describes your health
now as compared to
.
BETTER

Form SSA-455-OCR-SM (10-2013)

SAME
Continued on the Reverse

WORSE

FOR SSA USE ONLY

AC?

a. Have you gone to a doctor or clinic for treatment
(including evaluations, checkups, counseling,
prescriptions, or medicine) since
?

YES

b. If you answered “YES” to 5.a., please list:
Most
Recent
Visit

Reason For Visit:

Month

Year

1.
2.
3.

a. Have you been hospitalized or had surgery
since
?

YES

b. If you answered “YES” to 6.a., please list:
Most
Recent

Reason For Hospitalization or Surgery:

Month

Year

1.
2.
3.

REMARKS: If you use this space to further answer questions 1. through 6.,
place an “X” in the box to the right and print on the lines below.

I declare under penalty of perjury that I have examined all the information on this form,
and on any accompanying statements or forms, and it is true and correct to the best of
my knowledge. I understand that anyone who knowingly gives a false or misleading
statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.

SIGN HERE

TODAY’S DATE
TELEPHONE NUMBER (include Area Code)

Form SSA-455-OCR-SM (10-2013)

File Type	application/pdf
File Modified	2017-03-01
File Created	2014-07-28