Claimant's Recent Medical Treatment

Documents and Forms

Document Name Document Type
Form HA-4631 Claimant's Recent Medical Treatment Form
Privacy Act Statement 0292 (revised).docx www.ssa.gov Other-Revised Privacy Act Statement
PRA 0292 (revised).docx Other-Paper Reduction Act Statement
HA-4631 Claimant's Recent Medical Treatment HA-4631 (revised).pdf www.ssa.gov/online/ha-4631.html. Form
HA-4631(current).pdf HA-4631 Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claimant's Recent Medical Treatment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1512 20 CFR 416.912

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-4631	Claimant's Recent Medical Treatment	HA-4631 (revised).pdf	http://www.ssa.gov/online/ha-4631.html.	Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act Statement			Privacy Act Statement 0292 (revised).docx	www.ssa.gov	Yes	No	Printable Only
Other-Paper Reduction Act Statement revised			PRA 0292 (revised).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 190,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	190,000	-10,000	200,000
Annual IC Time Burden (Hours)	31,667	-1,666	33,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
HA-4631 Current Version	HA-4631(current).pdf	06/30/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.