Medical Consultant's Review of Physical Residual Functional Capacity Assessment

F m Approved

OMB No.0980-0880

REFERRING DDS
SN OF NUMBER HOLDER

- -

MEDICAL CONSULTANTS REVIEW
OF PHYSICAL RESIDUAL FUNCTIONAL
CAPACITY ASSESSMENT

CLAIMANr'S NAME
DATE(S) SSA-4734-BK APPLICABLE

-

PART A EVALUATION
SHOW AGREE OR DISAGREE WITH EACH SECTION OF THE SSA~MK
BELOW. (Plscuss each disagreement In Part 0 . )

BY CHECKING THE CORRESPONDING ITEMS

-

I. UMlTAllONS (Check "agreen If the DDS conclusions are reasonable and
ruppwted by evldenca In the file.)

I

AGREE

I

DISAGREE

a. EXERTIONAL LIMITATIONS

b. POSTURAL LIMITATIONS

c. MANIPULATIVE LIMITATIONS
d. VlSUAL LIMITATIONS

e. COMMUNICATIVE LIMITATIONS
f.

ENVIRONMENTAL LIMITATIONS

-

II. SYMPTOMS (Chedr "%me" if the DDS dlscussud ator documented
symptoms and agswsed symptMMslatd limltatlons, not Plmady addressed In
Section 1 of #re SSAQ734-BK)

-

Ill. TREATING OR EXAMINING SOURCE STATEMENTS ( C M"m"
If the DDS
dincussed all relevant W n g or examlnlng source atabmmts not alnady
discussed In Sections I or I1 of the SSA47344K.)

-

Cite each item In dispute (lee.,SSA-4734-BK d o n and item number).
For each item cited, show p u t concluskm and explain how and why the evidence supports these conclusions.
Annotate any necessary comments hen.

Form 8811592 (12-2004) d (12-2004) Use 4-2004 edltkn unmR stmly is -ted

(Continued on next page)

Form Selector

Page I of 1

The information rapesled on this form is ~ r l h o r h dby Spction 223 and Section 1633 of the Social S ~ u r i i yAct. The information
plovidcd.will bs uscd in m e i n n decisim q &is claim. Failwe to cunplsts the form may mull in a delay in pmea~insthe claim.
nfa-mn fmuhodn hu
may be aschard by h e social ~ r i l ~dm,n,rtnt,m
y
m amthcr p-n or gouomncnral
ngency ody 9
t
h m p c l to Social Secu? & programs and to cunpb with Fd-1 Iawa requiringthe ekchange of infmation
k w e m Soe~alSmniy and ahor nmc~m.
.

fkn

_

A

-

PART C COlCLWlON
t.

AGREE

2

DlS AGREE (WS SSA47348K is b m d on merit evidence, but conell-iions

h e evldsnee In fb.)

am not reasonableandor suworted by

Thefollowing revised PRA Statement will be inserfed into theform at its
next scheduled reprinting..
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S .C. 9 3 507, as amended by section 2 of the P a w o r k Reduction
Act of f 895. 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 12
minutes to read the instructions, gather the facts, and answer the questions. You may send
commends on our time estimate above to: SSA,640 1 Securily Blvd, Baltimore, MD
2 1235-6401. Send& t
commenf i relating to our dme estimate to thk address, not the
compIdedform.