Form HA-67 Request for Medical Evidence From a Hospital

SOCIAL SECURITY ADMINISTRATION
Refer To:
[ClaimantFirstName][ClaimantLastName]
[ClaimantDOB]

Office of Hearings Operations
Hearing Office Name
Hearing Office Address
Tel: (xxx)xxx-xxxx / Fax: (xxx)xxx-xxxx
[Today’s Date]

[Hospital Name]
[Hospital Address]

A claim for disability benefits, filed by the above-named individual under the Social Security
Act, is before the Office of Hearings Operations for hearing and decision.
Please provide the following information within the next ten days:
[Requested Information]
If you are currently registered as a user of the Electronic Records Express (ERE), use the
attached barcode information when submitting the requested evidence (RQID, RF, and DR
fields). If you are not a registered user of ERE, fax the evidence, along with the enclosed
barcode, using this fax number– [ScanFaxNumber]. Remember that the enclosed barcode must
be the first page of each set of documents being faxed. Note: If you request payment, the
request should be returned to the address shown above or sent via the fax number noted
below – it is different than the FECS fax number used for medical evidence.
Your assistance in furnishing this information will facilitate the adjudication of this claim and
will be greatly appreciated. A medical release form is enclosed. We are
authorized to pay up to $[FeeAmount], which is the same amount that the Disability
Determination Service Office pays for such a report. If you require payment for the evidence,
please supply us with the necessary information requested on the attached page and return this
letter by mail or fax [OfficeFaxNumber] to our office as soon as possible.
Please refer to the attached schedule for payment information.
We are not required to pay for medical evidence in this state. If you have any questions,
please contact [ContactFirstName] [ContactLastName] [SigneeName]
at the phone number listed above.
Thank you for your cooperation.

Sincerely,

Form HA-L67 (03-2007)

See Next Page

[SigneeName]
[SigneeTitle]
Enclosures

cc: [OBOName] on behalf of
[ClaimantFirstName][ClaimantLastName]
[OBOAddress]

[ClaimantFirstName][ClaimantLastName]
[ClaimantAddress]

Form HA-L67 (03-2007)

See Next Page

[Hospital Name]
[Hospital Address]
Medical Source Information (to be completed by physician)
Signature:

Amount:

Physician SSN or, if
incorporated, EIN:

Date:

or
Medical Center Name and
Federal Tax EIN:

Date:

Payee Name – Please Print:
(First, Middle Initial, Last
Name); Payee SSN, or if
incorporated, EIN: (The EIN or
SSN must belong to the payee.)

Date:

Remittance Address:
Telephone Number:
Hearing Office Information (to be completed by hearing office personnel)
Evidence Received by:
CAN:
TPD#

SOC:

Date:
APPROVED FOR PAYMENT BY:

PAID BY (INITIALS)

SYSTEMS ID NUMBER

DATE:
DATE:

See Revised
Privacy Act
Statement
Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act as amended, [42 U.S.C.
405(a), 1383(d)(1) and 1383(e)(1)] authorize us to collect this information. We will use the
information you provide to help us determine the amount of this claim. The information you provide
on this form is voluntary. However, failure to provide the requested information may prevent us from
making an accurate and timely decision on any claim filed.
Privacy Act Statement
Collection and Use of Personal Information

We rarely use the information you provide on this form for any purpose other than for the reasons
explained above. 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 or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
records to other agencies (e.g., to the Government Accountability Office, and the Department
of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs
at the Federal, State, and local level.
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 agencies 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 our System of Records Notices
entitled, Administrative Law Judge Working File on Claimant Cases, 60-0005 and Claims Folders
Systems, 60-0089. The notices, additional information regarding this form, and information
regarding our system and programs, are available on-line at www.socialsecurity.gov or at any local
Social Security office.

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d)(5), 1614(a)(3), and 1631(d)(1) 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 us from making an accurate and
timely decision on any claim filed.
We will use the information you provide to establish the named claimant’s rights to benefits or
payments. We may also share your information for the following purposes, called routine uses:
•

To contractors and other Federal agencies, as necessary, for the purpose of assisting
SSA in the efficient administration of its programs; and

•

To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for SSA as authorized by law,
and they need access to personally identifiable information in SSA records in order to
perform their assigned agency functions.

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) 60-0005, entitled Administrative Law Judge Working File on Claimant Cases, as
published in the Federal Register (FR) on April 29, 2009, at 74 FR 19617; and SORN 60-0089,
Claims Folders System, as published in the FR on October 31, 2019, at 84 FR 58422. Additional
information, and a full listing of all our SORNs, is available on our website at
www.ssa.gov/privacy.

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INSERT THIS END FIRST

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Please include this barcode cover sheet as the first page
of each set of documents returned.

Fax the evidence to this fax number:
[Scanner Phone number]

Sample Barcode above
Claimant: [Claimant Name]
SSN: [Claimant SSN]