Form SSA-392 Medical Consultant's Review of Physical Residual Functio

Form Approved
OMB No. OMM880

MEDICAL CONSULTANTS REVIEW
OF PHYSICAL RESIDUAL FUNCTIONAL
CAPACITY ASSESSMENT

SSN OF NUMBER HOLDER

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CLAIMANTS NAME
DATE@) SSA-4734-BK APPLICABLE

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PART A . EVALUATION
SHOW AGREE OR DiSAGREE WITH EACH SECTION OF THE SSA47344K BY CHECKING THE CORRESPONDING ITEMS
BELOW. (Mmm?each disegreement In Part B.)
1.

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UMlTAllOlrlS (Chedr "agns' lfth. DDS wndudonm are masclnabte and
s u m by the ovldmce In flla)

AGREE

DISAGREE

b. POSTURAL LIMITATIONS

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c. MANIPULATIVE LfMiTATIONS

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d. VISUAL LIMITATIONS
e. COMMUNICATIVE LIMITATIONS

f. ENVIRONMENTAL LIMITATIONS

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If. SYMPTOM8 (Check "mu
If the DDS dlscussd dlsgsd or do#rmmbd
symptom and
symptommlatsd Ilmltatlons, not dmdy
Seetlon I d the SSA473eBK)

in

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Ill, TREATING OR EXAMINING SOURCE STATEMENTS (M
"m"
If the DOS
d k u d all dsvant treatlng or wamlnlng sou- rtatsmsnts not already
dhcusssd In SsEtlona I or U ofthe SSA479681d)
I

tf*

have indicated agreement with all ofthe above, pmmd to Part C.

-,PARTs
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-D

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S ~ N
Cite each Item In dfqute O.e., SSA-47-K
sectton and item number).
For each Item cited, show your mndu8rons and explah hwv and w h y the evidence supp~rts
these o o n d W ~ .

Form SSA-392 (4-2004) ef (042004) Destroy rrlor Edlths

{Continued on next page)

The Privacy md Prpmork Red~ctlo8Ack

The information m q u d on thia faxm is a u t h d d by M m 223 end Saction 1633 of the Social Security Act. TtmE h f ~ m
rovided will ba dinma+gaddsionon this clalm.Faihmtocomp~thisformwmultinadelay i n w t h c c l a b .
Rformation fhnhbdo?tbur f- may be disclad by the Social SAdmini*
to motha prmm or g o v ~ d
only w~thrsepoot to Soad Smmty pmgmm a d to comply with Fcdasl aws mqwmg the -C
of w o n between=
Security d otha agaacies.

P

~ C - c o W c W ~
1 - 1 3 AGREE

2.

DISAGREE (00s SSA-QfaeBK la bm!d

on suffident dmce, but -uslone

are not reasormble a m wppdd by

the wmnm In flle.1
MEDICAL CONSULTANTS SlQNAfWIE

MC CODE

ThefuJlowiwg revised PRA Statement will be inserted into the form at its
rt ex$ scheduled reprinting:
Paperwork Reduction Act Statement - This information wllsction meets the
requirements of 44 U.S.C. 3 3 507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You da 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 12
minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate al~ur~e
to: SSA, 6401 S ~ c i ~ - iBlvd,
t y Baltimore, MD
2 1235-6401. Send & comments relating to our time e,mminate
to t h i ~
address, not the
completed form.