Form HA-4631 Claimant's Recent Medical Treatment

Social Security Administration

Form Approved
OMB No.0960-0292

CLAIMANT’S RECENT MEDICAL TREATMENT

A. To be completed by hearing office
(Claimant and Social Security Number)

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

B. To be completed by claimant

PLEASE PRINT
Please Answer the Following Questions:
(1) Have you been treated or examined by a doctor, or other health care provider, (other than being hospitalized) since the
above date?
Yes
No
(If yes, please list the name, addresses and telephone numbers of doctors, or other health care providers, who have
treated or examined you since the above date. Also list dates of treatment or examination. If possible, send updated
reports from these doctors, or other health care providers, to the judge prior to the date of your hearing.)
NAME(S) OF DOCTOR OR OTHER
ADDRESS(ES) & TELEPHONE NO.(S)
DATE(S)
HEALTH CARE PROVIDER

(2) What have these doctors, or other health care providers, told you about your condition?

(3) Have you been hospitalized since the above date?
Yes
No
(If yes, please list the name and address of the hospital. Also explain why you were hospitalized and what treatment you
received.)
Name of Hospital
Address of Hospital (Include ZIP Code)
Reason for hospitalization:

Treatment received:
Form HA-4631 (8-1996) ef (9-2012)
Issue Old Stock

If more space is needed,
use additional sheets.

Privacy Act Statement
Collection and Use of Personal Information

See Revised
Privacy Act
Sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (C) of the Social
Security Act, as
Statement
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 or could result in denial of the claim.
We will use the information to determine eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
1. To third party contacts in situations where the party to be contacted has, or is expected to
have, information relating to the individual’s capability to manage his or her affairs or his or
her eligibility for or entitlement to benefits under the Social Security program when the data
are needed to establish the validity of evidence or to verify the accuracy of information
presented by the individual, and it concerns his or her eligibility for benefits under the Social
Security program; and
2. To specified business and other community members and Federal, State, and local agencies
for verification of eligibility for benefits under section 1631(e) 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, and 60-0320, entitled Electronic Disability (eDIB) Claim
File. Additional information and a full listing of all our SORNs are available on our website at
www.ssa.gov/privacy/sorn.html.
See Revised
Paperwork
Paperwork Reduction Act Statement - This information collection
meets the requirements of 44
Reduction
Act You do not need
U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction
Act of 1995.
Statement
to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and
answer the questions. You may send comments on our time estimate above to: SSA, 1338 Annex
Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.
Form HA-4631 (8-1996) ef (9-2012)