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    Form HA-4632

    Uploaded by

    GARY SELLS
    This document is a form for a claimant to list their current medications, both prescription and non-prescription, for a Social Security Administration hearing. The form requests the name, date prescribed, daily dosage, and prescribing physician for any prescription medications, as well as non-prescription medications and reasons for taking them. It also provides privacy act and paperwork reduction statements regarding the collection and use of the personal medical information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Form HA-4632

    Uploaded by

    GARY SELLS
    263 views2 pages
    This document is a form for a claimant to list their current medications, both prescription and non-prescription, for a Social Security Administration hearing. The form requests the name, date prescribed, daily dosage, and prescribing physician for any prescription medications, as well as non-prescription medications and reasons for taking them. It also provides privacy act and paperwork reduction statements regarding the collection and use of the personal medical information.

    Original Description:

    How to Fill out Form HA-4632 (Medication List Form) in New Orleans

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    This document is a form for a claimant to list their current medications, both prescription and non-prescription, for a Social Security Administration hearing. The form requests the name, date prescribed, daily dosage, and prescribing physician for any prescription medications, as well as non-prescription medications and reasons for taking them. It also provides privacy act and paperwork reduction statements regarding the collection and use of the personal medical information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    263 views2 pages

    Form HA-4632

    Uploaded by

    GARY SELLS
    This document is a form for a claimant to list their current medications, both prescription and non-prescription, for a Social Security Administration hearing. The form requests the name, date prescribed, daily dosage, and prescribing physician for any prescription medications, as well as non-prescription medications and reasons for taking them. It also provides privacy act and paperwork reduction statements regarding the collection and use of the personal medical information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    SOCIAL SECURITY ADMINISTRATION Form Approved

    Office of Hearings and Appeals OMB No. 0960-0289

    CLAIMANT'S MEDICATIONS
    A. To be completed by Hearing Office
    (Claimant and Social Security Number) (Wage Earner and Social Security Number) The last time we brought
    (Leave blank if same as claimant) your case up-to-date was:

    - - - -
    B. To be completed by the claimant

    PLEASE PRINT
    PLEASE LIST BELOW THE PRESCRIPTION MEDICATION WHICH YOU ARE PRESENTLY TAKING. IF THE NAME
    OF THE MEDICATION IS NOT SHOWN ON THE PRESCRIPTION CONTAINER, YOU MAY VERIFY THE NAME WITH
    YOUR PHARMACIST.
    NAME OF DATE FIRST DAILY AMOUNT REASON FOR MEDICATION NAME OF
    MEDICATION & PRESCRIBED TAKEN PHYSICIAN
    DOSAGE

    PLEASE LIST BELOW THE NONPRESCRIPTION MEDICATION YOU ARE TAKING AND THE REASONS YOU TAKE THEM.

    Form HA-4632 (10-2012) ef (10-2012) If more space is needed,


    Use Until Stock Is Exhausted use additional sheets.
    Privacy Act Statement Collection and Use
    of Personal Information

    Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended authorize us to
    collect this information. We will use this information to evaluate your reason for failing to
    appear at your scheduled hearing.

    Furnishing us this information is voluntary. However, failing to provide us with all or part of the
    requested information may affect our ability to re-evaluate the decision on your claim.

    We rarely use the information you supply for any purpose other than for determining problems
    in Social Security programs. 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 and/or coverage;

    2. To comply with Federal Laws requiring the release of information from Social
    Security records (e.g., to the Government Accountability Office and the
    Department of VeteransAffairs);

    3. To make determinations for eligibility in similar health and income maintenance


    programs as at the Federal, State, and local level; and

    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 programs can be used to establish or verify a
    persons 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 Systems of Records
    Notices, 60-0009, Hearings and Appeals Case Control System, and 60-0010, Hearing Office
    Tracking System of Claimant Cases. These notices, additional information regarding our
    programs and systems, are available on-line at www.socialsecurity.gov or at any local Social
    Security office.

    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
    control number. We estimate that it will take about 15 minutes to read the instructions, gather
    the facts, and answer the questions. You may send comments on our time estimate above to:
    SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our
    time estimate to this address, not the completed form.
    Form HA-4632 (10-2012) ef (10-2012)
    Use Until Stock Is Exhausted

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