Form HA-67 Request for Evidence from Hospital

SOCIAL SECURITY ADMINISTRATION
Refer To:
DOB:

FORM APPROVED
OMB NO. 0960-0722

Office of Disability Adjudication and Review
Street Address City, State Zip Code
Tel:
Fax:
Date

A claim for disability benefits, filed by the above-named individual under the Social Security Act, is before
the Office of Hearings and Appeals for hearing and decision.

Please provide the following information within the next ten days:
Your assistance in furnishing this information will facilitate the adjudication of this claim and will be greatly
appreciated. A medical release form is enclosed. We are authorized to pay up to $
, which is the
same amount that the Disability Determination Service Office pays for such a report. If you require payment
for the evidence, please supply us with the necessary information requested on the attached page and return
this letter with the evidence to our office as soon as possible. If you have any questions, please contact
at the phone number listed above.
Thank you for your cooperation.

Sincerely,

Enclosures
cc:

Form HA-67 (XX-2007)

PRIVACY ACT STATEMENT
The Social Security Administration is authorized to collect the information on this form under sections 205(a),
223(d), 1614(a)(3)(H)(I) and 1631(d)(1) of the Social Security Act. The information on this form is needed by
Social Security to complete processing of the named patient's claim. While giving us the information on this
form is voluntary, failure to provide the requested information may prevent an accurate or timely decision on
the named patient's claim. Although the information you furnish on this form is almost never used for any
purpose other than making a determination about disability, such information may be disclosed by the Social
Security Administration to another person or governmental agency only with respect to Social Security
programs and to comply with federal laws requiring the exchange information between Social Security and
another agency.
Explanations about these and other reasons why information about you may be used or given out are available
in Social Security offices. If you want to learn more about this, contact any 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. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. To find the
nearest office, call 1-800-772-1213. Send only comments on our time estimate above to: SSA, 6401 Security
Blvd., Baltimore, MD 21235-6401.

Form HA-67 (XX-2007)