Form SSA-455 Disability Update Report

FORM APPROVED
OMB NO. 090-0511

SOCIAL SECURITY ADMINISTRATION

Social Security Administration Disability Update Report
Information and Completion Instructions
Why We Are
Writing To
You Now

The Social Security Administration must regularly review the cases of people getting disability
benefits to make sure they are still disabled under our rules. It is time for us to review this
case. Enclosed is a Disability Update Report for you to answer to update us about you (or
the person for whom you are the representative payee), your health and medical conditions,
any recent work activity, or any recent training.

What To Do First

Please read the following information, and the instructions for completing the report form,
before you answer the questions.

When to Respond

Please complete the report and then sign the form digitally within 30 days of receiving the
mailed Disability Update Report. To provide your digital signature, you will need to provide an
email address. You will receive an email from echosign@echosign.com asking you to confirm
your digital signature. If you do not receive the confirmation email within a few minutes of
submitting your email address, please check your email Junk folder in case the confirmation
was delivered there instead of your inbox. YOUR SIGNATURE IS NOT COMPLETE AND
YOUR APPLICATION WILL NOT BE PROCESSED UNTIL YOU COMPLETE THE
INSTRUCTIONS IN YOUR EMAIL. If you have questions, call Social Security at
1-800-772-1213. TTY users should call 1-800-325-0778.

What We Do With
Your Answers

We consider the information you give us together with the information in your claim record to
decide if we need to do a full medical review. After we receive the completed report, we will
notify you whether or not we need to do a full medical review.

If You Need Help
To Answer The
Report

It is important that information you give us is accurate. We have tried to make report
questions easy to understand and answer. But, if you find that you do not understand a
question or questions, please contact us, your authorized representative, a social service
agency, your doctor or clinic, or some other person you trust.

If You Need To
Contact Us

If you need to contact us, please call us toll-free at 1-800-772-1213
or TTY for the hearing impaired at 1-800-325-0778. We can answer most questions over the
telephone. If you prefer to visit or call one of our offices, please use the 800 number to get the
local office address and telephone number. Please have the Disability Update Report with
you if you call or visit an office. It will help us answer your questions. Also, if you plan to visit
an office, you should call ahead to make an appointment. This will help us serve you.

We May Need To
Contact You

Sometimes, we may need more information from you. If so, we will try to call you. If you do
not have a telephone, please give us a number where we can leave a message for you.
Please print the telephone number in the section provided on the back of the report form.

If We Don't Hear
From You

If you do not complete and return the report promptly, or tell us why you cannot respond, we
may stop sending payments to you. If it is necessary to stop your payments, we will send you
another letter telling you what we plan to do.

If We Do A Full
Medical Review

If we decide to do a full medical review of your case, you can give us any information which
you believe shows that you are still disabled, such as medical reports and letters from your
doctors about your health. Then, we look at all your information in your case, including the
new information you give us, and decide whether you continue to be disabled under our
rules.

Appeals And
Continued
Benefits

When we review your case, we may find that you are no longer disabled under our rules, and
your payments may stop. If your payments stop, you can appeal our decision or you can ask
us to continue to make payments while you appeal.

Form SSA-455 (08-2014)

FORM APPROVED
OMB NO. 090-0511

SOCIAL SECURITY ADMINISTRATION

If You Want
To Work
The Privacy And
Paperwork
Reduction Acts
See Revised Privacy
Act & PRA Statements
attached.

Do you want to work, but worry about losing your payments or Medicare before you can
support yourself? We want to help you go to work when you are ready. But, work and
earnings may affect your benefits. Your local Social Security office can tell you more about
work incentives, and how work and earnings can affect your benefits.
Privacy Act Statement Collection and Use of Personal Information - Sections 205(a), 221(i),
223(d), 1614(a)(4), 1631(e)(l), and 1633(a) and (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 us from making an accurate and timely decision on any claim filed.
We will use the information to make a determination of continued eligibility for benefits. We may also
share your information for the following purposes, called routine uses:
1. 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 the Social Security Administration (SSA) or a State agency acting in accord with sections
221 or 1633 of the Act; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the
efficient administration of its programs. We contemplate disclosing information under this routine use
only in situations in which SSA may enter a contractual agreement with a third party to assist in
accomplishing an agency function relating to this system of records.
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 Notice (SORN)
60-0089, entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are
available on our website at www.socialsecurity.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 (0MB) control
number. The 0MB control number for this collection is 0960-0511. We estimate that it will take 15
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.

HOW TO FILL OUT THE REPORT FORM
QUESTION 1.a.
-Have You
Worked?

If you have not worked within the last 2 years, mark "NO", and go on to question 2. If you
have worked, mark "YES", and answer question 1.b.

QUESTION 1.b.
-When You
Worked And Your
Monthly Earnings

Describe your most recent work activity first. Enter the months and years you began and
ended working in the boxes under "Work Began" and "Work Ended." If you are working
now, enter the current month and year in the first set of boxes under "Work Ended." Enter
your gross monthly earnings for the periods you worked in the boxes.

QUESTION
2-School Or Work
Training

Mark "YES" if you have attended school and/or a training program within the last 2 years;
otherwise, mark "NO". This could include high school equivalency programs, college
courses, vocational evaluation or retraining programs, but generally would not include group
therapy or hobbies. Mark only 1 box.

Form SSA-455 (08-2014)

SOCIAL SECURITY ADMINISTRATION

FORM APPROVED
OMB NO. 090-0511

QUESTION 3-Can
You Work?

Tell us if you have discussed with your doctor whether you can return to any kind of work, and if
so, whether the doctor told you that you can return to work, even if the work permitted is less
physically demanding and/or less stressful than your usual work. Mark only 1 box.

QUESTION 4 How
Is Your Health?

We want to know how your overall health now compares to what it was 2 years ago. You may
feel that your health has gotten worse, has improved, or you may feel that your health is about
the same and has not gotten better or worse. Mark only 1 box.

QUESTION 5Treatment By A
Doctor Or Clinic

A "doctor or clinic" can include treatment such as evaluations, checkups, counseling,
providing prescriptions or medicine by a doctor, visiting nurse, family health center,
psychologist, licensed counseling service, physical therapist, a chiropractor or other licensed
health provider. Treatment may be provided in person or by telephone or other contact.

How To Answer
Question 5.a.

If you have not been treated by a doctor or clinic within the last 2 years, mark "NO", and go
on to question 6. If you have gone to a doctor or clinic within the last 2 years, mark "YES",
and answer question 5.b.

Question 5.b.Reason For The
Visit

Please start with the most recent visit and then work backwards in time. Enter as much
information as will fit. Try to use the most important or key word(s), such as ARTHRITIS or
BAD BACK, or HYPERTENSION or HIGH BLOOD. Your medical bills or doctor can provide
a short, accurate description.
Date of Visit Enter the month and year you were treated. For example, enter September 10,
2003, as 09/03.

QUESTION 6.a Have You Been
Hospitalized Or
Had Surgery?

Mark "NO" if you have not been hospitalized or not had surgery within the last 2 years. If you
have been hospitalized or had surgery within the last 2 years, then mark "YES" and answer
question 6.b.

Question 6.b. Reason For
Treatment

Please report your most recent treatment first and then work backwards in time. Try to
provide the most important information. Your medical bills or doctor can provide short, accurate
words.

Date of Treatment

Enter the month and year you were hospitalized or had surgery.
If you were hospitalized more than one month, enter last month you were hospitalized.

Remarks Section

If you need more room to answer questions 1.b., 5.b. and/or 6.b., or there are any other facts
or statements you want us to consider, select the checkbox and enter the information in this
section.

Signature, Date
and Telephone
Sections

Please complete and digitally sign the report form by typing your name as you usually sign
your name. Please provide a telephone number where you can be reached during the day.
To provide your digital signature, you will need to provide an email address. You will receive an
email from echosign@echosign.com asking you to confirm your digital signature. If you do not
receive the confirmation email within a few minutes of submitting your email address, please
check your email Junk folder in case the confirmation was delivered there instead of your
inbox. YOUR SIGNATURE IS NOT COMPLETE AND YOUR APPLICATION WILL NOT BE
PROCESSED UNTIL YOU COMPLETE THE INSTRUCTIONS IN YOUR EMAIL.

Form SSA-455 (08-2014)

Disability Update Report

FORM APPROVED
OMB NO. 0960-0511

Social Security Administration
BENEFICIARY’S NAME AND ADDRESS
Name
Street Address

REPORT PERIOD
Last 2 years to Present

TELEPHONE NUMBER

City

State

SOCIAL SECURITY NUMBER

Zip Code

PAYEE'S NAME AND ADDRESS (if different from above)
Name
Street Address
City

State

Zip Code

Please be sure to read the instructions before completing the form. Finally, remember that when answering the
questions, we need information about you from the last 2 years to the present. If you have any questions, call
1-800-772-1213 or TTY for the hearing impaired at 1-800-325-0778.

1.

a. In the last 2 years, have you worked for someone or been

YES

NO

self-employed?
b. If you answered “YES” to 1.a., please complete the information below.
WORK BEGAN

Most
Recent
Work

Month/Year (mm/yy)

WORK ENDED

Dollars Only, No Cents

1.

$

2.

$

3.

$

2.

In the last 2 years, have you attended any school or work training

3.

In the last 2 years to present ...(Please select only one box):

4.

MONTHLY EARNINGS

Month/Year (mm/yy)

YES

NO

program(s)?

my doctor and I
have not discussed
whether I can work.

my doctor
told me I
cannot work.

my doctor
told me I
can work.

Place select only one box which best describes your health
now as compared to the last 2 years.
BETTER

Form SSA-455-OCR-SM (10-2013)

SAME

WORSE

FOR SSA USE ONLY

AC?

5.

a. Have you gone to a doctor or clinic for treatment
(including evaluations, checkups, counseling,
prescriptions, or medicine) in the last 2 years?

YES

NO

b. If you answered “YES” to 5.a., please list:
Most
Recent
Visit

Reason For Visit:

Month/Year (mm/yy)

1.
2.
3.

6.

a. Have you been hospitalized or had surgery
in the last 2 years?

YES

NO

b. If you answered “YES” to 6.a., please list:
Most
Recent

Reason For Hospitalization or Surgery:

Month/Year (mm/yy)

1.
2.
3.

REMARKS: If you use this space to further answer questions 1. through 6.,
select the box to the right and type on the space below.

ATTACH FILES: If you have additional information, please feel free to attach.
Only attach PNG, JPG, JPEG, GIF, BMP, PDF, DOC, DOCX, WP, TXT, RTF, HTM, or HTML file
types. Attachments are limited to 5 MB and 25 Pages

Click to attach a file.

Form SSA-455-OCR-SM (10-2013)

Click to attach a file.

I declare under penalty of perjury that I have examined all the information on this form,
and on any accompanying statements or forms, and it is true and correct to the best of
my knowledge. I understand that anyone who knowingly gives a false or misleading
statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.

SIGN HERE

TELEPHONE NUMBER (include Area Code)

After completing the form, click on the “Click to Sign” button at the bottom of the form to complete the
digital signature process. You will need to provide an email address. You will receive an email from
echosign@echosign.com asking you to confirm your digital signature. YOUR SIGNATURE IS NOT
COMPLETE AND YOUR APPLICATION WILL NOT BE PROCESSED UNTIL YOU COMPLETE
THE INSTRUCTIONS IN YOUR EMAIL.

Form SSA-455-OCR-SM (10-2013)

SSA will insert the following revised Privacy Act & PRA Statements 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)(4), and 1633(a) and (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 accurate and timely
processing of the disability case for review.
We will use the information you provide to make a determination of continued eligibility for
benefits. We may also share the information for the following purposes, called routine uses:
•

To private medical and vocational consultants, for use in preparing for, or evaluating
the results of, consultative medical examinations or vocational assessments which
they were engaged to perform by us or a State agency, in accordance with sections
221 or 1633 of the Social Security Act; and,

•

To contractors or other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of its programs.

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 Notice
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
October 31, 2019, at 84 FR 58422. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.

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 15 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.