Form SSA-199 Vocational Rehabilitation Provider Claim

Form Approved
OMB No. 0960-0310

Social Security Administration

VOCATIONAL REHABILITATION PROVIDER CLAIM
From:

To:
Social Security Administration
Office of Employment Support Programs VRA Operations Team
P.O. Box 17714
Baltimore, Maryland 21235-7714

VR Provider
Code
Check One

Claim Based On:

Continuous Period of SGA

Medical Recovery during VR

If claim is based upon other than a continuous period of SGA, it is not necessary to complete items 6, 8, 9, or 13 below.
Check One

Initial Claim

Reconsideration

Resubmittal

Supplemental

1. Client (First Name, MI, Last Name)
2.

SSA

SSN (Primary)

3. SSN (Widow or child, if
appropriate)

4.

Blind

SSI
5a. Date Client Entered 5b. Date Signed
VR OO
IPE

Non-Blind
6. Date Employment 7. Date of Final VR
Began
Closure

8. Months Work Activity Tracked After
VR Closing (show months)

9. Medical services were provided, initiated, or coordinated under IWRP

Yes

No

10. Claim based solely on extended evaluation services (VR 06)

Yes

No

11. Direct cost during VR (after 9/30/81) - Total from Item 17d (over)

$

12. Administrative, counseling and placement costs during VR (after 9/30/81)

$

13. Administrative costs only for tracking after VR (after 9/30/81)

$

14. Other (identify in Remarks section below)

$

15. Total amount claimed

$

16. What type of occupation(s) did the client perform during the continuous period of SGA:

Remarks:

Signature

Form SSA-199 (10-2015) UF (10-2015)
Destroy prior editions

Title

Page 1

Date

17. Itemization of direct cost services provided during the period of VR (after 9/30/81): (Use additional sheets as needed)
17a.

Date of Service

17b.

Type of Service

17c

Cost of Service

#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#11
#12
#13
#14
#15
17d. Total of column 17c (also enter in item 11 - over)

See Revised Privacy Act & PRA
Collection and Use of Personal Information Statements Attached
Privacy Act Statement

Sections 205(a), 222(d)(1), and 1615(d) of the Social Security Act, as amended, authorize us to collect the information. We will
use this information to determine claim eligibility.
Furnishing us this information is voluntary. However, failing to provide all or part of the information could prevent us from making
an accurate decision on the claim determination.
We rarely use the information you supply for any purpose other than the reason stated above. However, we may use the
information for the administration of our programs, including sharing information:
1. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government
Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of
our programs (e.g., to the Bureau of the Census and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our Privacy Act System of Records
Notices entitled, Master Beneficiary Record, 60-0090 and Vocational Rehabilitation Reimbursement Case Processing System,
60-0221. Additional information about these and other system of records notices and our programs, is available on-line at
www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other 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 matching
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. We estimate that it will take about 23 minutes to read the instructions, gather
the facts, and answer the questions. You do not need to answer these questions unless we display a valid Office of Management
and Budget control number. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.
www.socialsecurity.gov/work
Form SSA-199 (10-2015) UF (10-2015)

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