Form SSA-454-BK Continuing Disability Review Report

CONTINUING DISABILITY REVIEW REPORT SSA-454-BK
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The office that reviews your medical condition will use the information in this report. The information
will help that office decide whether you are still disabled. Please complete as much of the report as
you can.
IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask your
health care provider to complete this report. If you cannot complete the report, a Social Security
Representative will assist you. If you have an appointment, please have the completed report ready
when we contact you.
Note: If you are assisting someone else with this report, please answer the questions as if that
person were completing the report.
HOW TO COMPLETE THIS REPORT
•

Print or write clearly.

•

Include a ZIP or postal code with each address.

•

Provide complete phone numbers, including area code. If a phone number is outside the United
States, provide International Direct Dialing (IDD) code and country code.

•

If you cannot remember the names and addresses of your health care providers, you may be
able to get that information from the telephone book, Internet, medical bills, prescriptions, or
prescription medicine containers.

•

ANSWER EVERY QUESTION, unless the report indicates otherwise. If you do not know an
answer, or the answer is "none" or "does not apply," please write: "don't know," or "none," or
"does not apply."

•

Be sure to explain an answer if the question asks for an explanation or if you want to give
additional information.

•

If you need more space to answer any question, please use Section 11 - Remarks, on the last
page to finish your answer. Write the number of the question you are answering.
YOUR MEDICAL RECORDS

If you have any of your medical records covering the last 12 months, send or bring them to our
office with this completed report. Please tell us if you want to keep your records so we can return
them to you. If you have a scheduled appointment for an interview, bring your medical records, your
prescription medicine containers (if available), and the completed report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS
THAT YOU DO NOT ALREADY HAVE. With your permission, we will request your records. The
information that you give us on this report tells us where to request your medical and other records
Form SSA-454-BK (04-2014) ef (04-2014)

Privacy Act Statement
See Revised Privacy Act and
Collection and Use of Personal Information PRA Statements Attached
Sections 205(a), 221(i), 223(d), 1614(a)(3), 1631(e)(1), and 1633(c) of the Social Security Act, as
amended, authorize us to collect this information. Furnishing us this information is voluntary.
However, failing to provide all or part of the information may prevent an accurate and timely
decision on any claim filed.
We will use the information to make a determination of eligibility for benefits. We may also share
your information for the following purposes, called routine uses:
1. To third party contacts such as private collection agencies and credit reporting agencies under
contract with the Social Security Administration (SSA) and State motor vehicle agencies for the
purpose of their assisting SSA in recovering overpayments;
2. To State agencies to enable those agencies which have elected Federal administration of their
supplementation programs to monitor changes in applicant/recipient income, special needs, and
circumstances; and
3. To employers or former employers for correcting and reconstructing earnings records and for
Social Security tax purposes.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts
under these programs.
A list of routine uses is available in our Privacy Act System of Records Notices (SORNs) 60-0089,
entitled Claims Folders System; 60-0090, entitled Master Beneficiary Record; 60-0103, entitled
Supplemental Security Income Record and Special Veterans Benefits; and 60-0320, entitled
Electronic Disability Claim File. Additional information and a full listing of all our SORNs are
available on our website at www.social security.gov/foia/bluebook.
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. We estimate that it will take about 60 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.
SEND OR BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL SECURITY OFFICE,
THE NEAREST U.S EMBASSY OR CONSULATE OFFICE. Office addresses are listed under
U.S. Government agencies in your telephone directory or you may call 1-800-772-1213 (TTY
1-800-325-0778) for the address.
AFTER COMPLETING THIS FORM, REMOVE THIS SHEET AND KEEP IT FOR YOUR RECORDS.

xc vc x

Form SSA-454-BK (04-2014) ef (04-2014)

CONTINUING DISABILITY REVIEW REPORT
For SSA Use Only - Do not write in this box.
Date of your last medical disability decision:
Claim Number:

Number Holder:

Type(s) of Case(s):

TITLE II

DIB

DWB

CDB

FZ

ESRD

HIB

(Check all that apply.) TITLE XVI

DC
BI
BS
BC
DI
DS
If you are filling out this report for the disabled person, please provide information about him or her.
When a question refers to "you", "your", or the "disabled person", it refers to the person receiving
disability benefits.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
1.B. SOCIAL SECURITY NUMBER

1.A. NAME (First, Middle Initial, Last)

1.C. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
CITY

STATE/Province ZIP/Postal Code

COUNTRY (if not USA)

1.D. RESIDENT ADDRESS (Street or PO Box) Include apartment number if applicable
CITY

STATE/Province ZIP/Postal Code

COUNTRY (if not USA)

1.E. DAYTIME PHONE NUMBER, including area code, and the IDD and country codes if you
live outside the USA or Canada.
Phone Number:
Check this box if you have a phone or a number where we can leave a message
1.F. ALTERNATE PHONE NUMBER, including area code where we may reach you, if any.
Alternate Phone Number:
1.G. Can you speak and understand English?
If NO, what language do you prefer?

YES

NO

If you cannot speak and understand English, we will provide an interpreter free of charge.
1.H. Can you read and understand English?
YES
NO
1. I. Can you write more than your name in English?
YES
NO
1.J. Have you used any other names on your medical or educational records in the last 12 months?
Examples are maiden name, other married names, or nickname.
YES
NO
If YES, please list
SECTION 2 - CONTACTS
Give the name of a friend or relative (other than your doctors) we can contact who knows about
your medical conditions, and can help you with your case.
2.A. NAME (First, Middle Initial, Last)
Form SSA-454-BK (04-2014) ef (04-2014)

2.B. Relationship to Disabled
Page 3

SECTION 2 - CONTACTS (Continued)
2.C. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

2.D. DAYTIME PHONE NUMBER (as described in 1.D. above)
2.E. Can this person speak and understand English?
If NO, what language is preferred?

YES

NO

2.F. Who is completing this report?
The disabled person listed in 1.A. (Go to Section 3 - Medical Condition(s))
The person listed in 2.A. (Go to Section 3 - Medical Condition(s))
Someone else (Complete the rest of Section 2 below)
2.G. NAME (First, Middle Initial, Last)

2.H. Relationship to Disabled

2.I. DAYTIME PHONE NUMBER (as described in 1.D. above)
2.J. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

SECTION 3 - MEDICAL CONDITION(S)
3.A. If you are an adult (age 18 or older), list the physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. If you are completing this report
for a child (under age 18), list the physical and/or mental condition(s) (including emotional and
learning problems) that limit the child's ability to do the same things as other children the same
age. List each physical and/or mental condition separately.
1.
2.
3.
4.

If you need more space go to Section 11 - Remarks
3.B. What is your height without shoes?
3.C. What is your weight without shoes?

feet

pounds

inches

OR

OR

centimeters (if outside USA)

kilograms (if outside USA)

3.D. Do you use an assistive device (for example: eye glasses, hearing aids, braces, canes,
crutch(es), walker, wheelchair, service animal)?
Always
Sometimes
Never
If ALWAYS OR SOMETIMES, please describe what kind, when, and how you use it.
If you need more space, use SECTION 11 - Remarks
Form SSA-454-BK (04-2014) ef (04-2014)

Page 4

SECTION 4 - MEDICAL TREATMENT
Within the last 12 months, have you seen a doctor or other health care professional, or received
treatment at a hospital or clinic, or do you have a future appointment scheduled:
4.A. For any physical conditions
Yes
No
4.B. For any mental condition(s) (including emotional or learning problems)
Yes

No

If you answered "No" to both 4.A. and 4.B., go to Section 5 – Medicines Other medical
Information on page 9 on page 11.
4.C. Tell us who may have medical records covering the last 12 months about any of your
physical or mental condition(s) (including emotional or learning problems). This includes
doctors' offices, hospitals (including emergency room visits), clinics, and other health care
facilities. Tell us about your next appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER

PATIENT ID# (if known)

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or
2. Emergency Room Visits 3. Overnight Hospitals Stays
Outpatient visits
List the most recent date first
First visit

A.

Last visit

Next Scheduled Appointment B.
(if any)

C.

A. Date in

Date out

B. Date in

Date out

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in
this box.)
dfg

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need
to list more tests, use Section 11 - Remarks.
8 Form SSA-454-BK

Page 5

Check this box if no tests by this provider or at this facility.
KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

DATES OF TEST(S)

EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)

EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)

Hearing Test
Speech/Language Test
Vision Test
Breathing test

MRI/CT Scan (list body part)

Other

If you do not have any more doctors or hospitals to describe, go to Section 5 Medicines on page 9 on page 11.
4.D. Tell us who may have medical records covering the last 12 months about any of your physical
or mental condition(s) (including emotional or learning problems). This includes doctors'
offices, hospitals (including emergency room visits), clinics, and other health care
facilities. Tell us about your next appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER

PATIENT ID# (if known)

MAILING ADDRESS
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or
2. Emergency Room Visits 3. Overnight Hospitals Stays
Outpatient visits
List the most recent date first
First visit
Last visit

A.

Next Scheduled Appointment B.
(if any)

C.
What medical conditions were treated or evaluated?

8 Form SSA-454-BK

Page 6

A. Date in

Date out

B. Date in

Date out

C. Date in

Date out

What treatment did you receive for the above conditions? (Do not describe medicines or tests in
this box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need
to list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

DATES OF TEST(S)

EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)

EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)

Hearing Test
Speech/Language Test
Vision Test
Breathing test

MRI/CT Scan (list body part)

Other

If you do not have any more doctors or hospitals to describe, go to Section 5 Medicines on page 9 on page 11.
4.E. Tell us who may have medical records covering the last 12 months about any of your physical
or mental condition(s) (including emotional or learning problems). This includes doctors'
offices, hospitals (including emergency room visits), clinics, and other health care
facilities. Tell us about your next appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER

PATIENT ID# (if known)

MAILING ADDRESS
CITY

8 Form SSA-454-BK

STATE/Province

Page 7

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or
2. Emergency Room Visits 3. Overnight Hospitals Stays
Outpatient visits
List the most recent date first
First visit

A.

Last visit

Next Scheduled Appointment B.
(if any)

C.

A. Date in

Date out

B. Date in

Date out

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in
this box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need
to list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)

EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)

Hearing Test
Speech/Language Test
Vision Test
Breathing test

MRI/CT Scan (list body part)

DATES OF TEST(S)

Other

If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 9.
4.F. Tell us who may have medical records covering the last 12 months about any of your physical
or mental condition(s) (including emotional or learning problems). This includes doctors'
offices, hospitals (including emergency room visits), clinics, and other health care
facilities. Tell us about your next appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE
8 Form SSA-454-BK

NAME OF HEALTHCARE PROFESSIONAL THAT TREATED YOU
Page 8

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER

PATIENT ID# (if known)

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or
2. Emergency Room Visits 3. Overnight Hospitals Stays
Outpatient visits
List the most recent date first
First visit
Last visit

A.

Next Scheduled Appointment B.
(if any)

C.

A. Date in

Date out

B. Date in

Date out

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in
this box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need
to list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST

DATES OF TEST(S)

EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)

KIND OF TEST

DATES OF TEST(S)

EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)

MRI/CT Scan (list body part)
Hearing Test
Speech/Language Test
Vision Test
Other
Breathing test
If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 9 on page 11.

Form SSA-454-BK

Page

4.G. Tell us who may have medical records covering the last 12 months about any of your physical
or mental condition(s) (including emotional or learning problems). This includes doctors'
offices, hospitals (including emergency room visits), clinics, and other health care
facilities. Tell us about your next appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER

PATIENT ID# (if known)

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or
2. Emergency Room Visits 3. Overnight Hospitals Stays
Outpatient visits
List the most recent date first
First visit
Last visit

A.

Next Scheduled Appointment B.
(if any)

C.

A. Date in

Date out

B. Date in

Date out

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in
this box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need
to list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.

Form SSA-454-BK

Page

KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)

EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)

Hearing Test
Speech/Language Test
Vision Test
Breathing test

MRI/CT Scan (list body part)

DATES OF TEST(S)

Other

If you need to list more doctors or hospitals use Section 11 - Remarks and give the same
detailed information as above for each one you list.
SECTION 5 - MEDICINES
5. Are you now taking, or have you taken in the last 12 months, any prescription or non-prescription
medicines?
Yes (Complete the following information. Look at your medicine containers, if necessary.)
No (Go to section 6 - Other Medical Information on page 10.)
IF PRESCRIBED, GIVE
NAME OF MEDICINE
REASON FOR MEDICINE
NAME OF DOCTOR

If you need to list other medicines use Section 11 - Remarks.
If you are under age 18, Skip to Section 11 - Remarks.

Form SSA-454-BK

Page 11

SECTION 6 - OTHER MEDICAL INFORMATION
Complete only if you are age 18 years or older
6. Does anyone else have medical information about your physical or mental condition(s)
(including emotional and learning problems) covering the last 12 months, or are you scheduled
to see anyone else? (This may include places such as workers' compensation, vocational
rehabilitation, insurance companies who have paid you disability benefits, prisons, attorneys,
social service agencies and welfare agencies.)
Yes (Complete the following information.)
(Go to SECTION 7 - Education and Training.)
NAME OR ORGANIZATION
PHONE NUMBER
MAILING ADDRESS
CITY

ZIP/Postal Code

STATE/Province

NAME OF CONTACT PERSON

COUNTRY (if not USA)

CLAIM NUMBER (if any)

Date First Contact (in last 12 months) Date Last Contact (in last 12 months) Date Next Contact (if any)

Reason(s) for Contacts
If you need to list other people or organizations use Section 11 - Remarks and give the
same detailed information as above for each one you list.
SECTION 7 - EDUCATION AND TRAINING
Complete only if you are age 18 years or older
7.A. Have you received any education since your last disability decision? (See date at top of page 3 1)
NO, go to question 7.B below

YES (Complete the information below.)
If YES, what year did you last attend school?
Please describe the education you received.
NAME OF SCHOOL
CITY
TYPE OF PROGRAM/DEGREE

DATE(S) OF ATTENDANCE
_______/_________ to _________/______________
MM
YYYY
MM
YYYY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

Date Completed (or scheduled to be completed)
____________/________________
MM
YYYY

7.B. Have you received any type of specialized job, trade, or vocational training since your last
disability decision? (See date at top of Page 1.)
YES (Complete the information below.)
NO
PHONE

NAME OF TRAINING FACILITY
MAILING ADDRESS
Form SSA-454-BK

Page

STATE/Province

CITY
TYPE OF PROGRAM

ZIP/Postal Code

COUNTRY (if not USA)

Date Completed (or scheduled to be completed):
________/__________
MM
YYYY

7.C. What written language do you use every day in most situations (at home, work, school, in
community, etc.)? ______________________________
7.D. In the language you identified in 7.C., can you read a simple message, such as a shopping list or
short and simple notes?
YES
NO
7.E. In the language you identified in 7.C., can you write a simple message, such as a shopping list or
short and simple notes?
YES
NO
________________________________________________________________________________
If you need to list other education information or training facilities use Section 11 - Remarks
and give the same detailed information as above____________________
SECTION 8 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
Complete only if you are age 18 years or older
8.A. Since the date of your last medical disability decision (see date on top of Page 1), have
you participated, or are you participating, in:
• an individualized work plan with an employment network under the Ticket to Work Program;
• an individualized plan for employment with a vocational rehabilitation agency or any
other organization;
• a Plan to Achieve Self-Support (PASS);
• an Individualized Education Program (IEP) through a school (if a student age 18-21); or
• any program providing vocational rehabilitation, employment services, or other support
services to help you go to work?
NO (Go to Section 9 - Daily Activities)

YES (Complete the information below.)
If YES, what year did you last attend any school?
NAME OF ORGANIZATION OR SCHOOL

NAME OF COUNSELOR, INSTRUCTOR OR JOB COACH

PHONE NUMBER

MAILING ADDRESS
CITY

STATE/Province

ZIP/Postal Code

8.B. When did you start participating in the plan or program?
8.C. Are you still participating in the plan or program?

Form SSA-454-BK

Page

COUNTRY (if not USA)

YES, I am scheduled to complete the plan or program on: ________________________
(date to be completed)
NO, I completed the plan or program on: _________________________
(date completed)
NO, I stopped participating in the plan before completing it because:
8.D. What types of services, tests, or evaluations were provided (for example: intelligence or
psychological testing, vision or hearing tests, physical exam, work evaluations, or
classes?)

If you need to list another plan or program use Section 11 - Remarks and give the same
detailed information as above
SECTION 9 - DAILY ACTIVITIES
Complete only if you are at age 18 years old or older
9.A. Describe what you do in a typical day (for example: I get up around 7 A.M., take a shower, eat
breakfast, etc.)

If you need more space, go to Section 11 - Remarks
9.B. Do you have hobbies or interests?
YES

NO

If YES, please describe what they are and much time you spend doing them.

9.C. Do you ever have difficulty doing any of the following? (Please explain any "Yes" answers.)
Dressing
Bathing
Caring for hair
Taking medicines
Preparing meals
Feeding self
Doing chores (inside/outside house)
Driving or using public transportation
Shopping
Managing money
Walking
Standing
Form SSA-454-BK

YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Page

NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO

Lifting objects
Using arms
Using hands or fingers
Sitting
Seeing, hearing, or speaking
Concentrating
Remembering
Understanding or following directions
Completing tasks
Getting along with people

YES
YES
YES
YES
YES
YES
YES
YES
YES
YES

NO
NO
NO
NO
NO
NO
NO
NO
NO
NO

SECTION 10 - WORK
Complete only if you are age 14 years old or older
10. Since the date of your last medical disability decision have you worked? (see date at top of
Page 31) YES (If yes, we may contact you for additional information)
NO
SECTION 11 - REMARKS
Please write any additional information you did not give in earlier parts of this report. If you did not
have enough space in the sections of this report to write the requested information, please use this
space to tell us the additional requested in those sections. Be sure to show the section to which
you are referring.

Form SSA-454-BK

Page

Date Report Completed (month, day, year)

Form SSA-454-BK

Page

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 221(i), 223(d), 1614(a), 1631(e), and 1633(c) of the Social Security Act, as
amended, allow us to collect this information. Furnishing us this information is voluntary.
However, failing to provide all or part of the information may prevent an accurate and timely
decision on any claim filed.
We will use the information to determine eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•

To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representatives or representative payees to the extent necessary to pursue
Social Security claims and to representative payees when the information pertains to
individuals for whom they serve as representative payees, for the purpose of assisting
Social Security Administration (SSA) in administering its representative payment
responsibilities under the Act and assisting the representative payees in performing their
duties as payees, including receiving and accounting for benefits for individuals for
whom they serve as payees; and

•

To private medical and vocational consultants for use in making preparation for, or
evaluating the results of, consultative medical examinations or vocational assessments
which they were engaged to perform by SSA or a State agency acting in accord with
sections 221 or 1633 of the Act.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, and 60-0320, entitled Electronic Disability Claim File, as
published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full
listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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. We estimate that it will take about
60 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments regarding this burden estimate or any other aspect of this collection,
including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.