Form SSA-3826 Medical Report (General)

Form Approved.
OMB No. 0960-0052

SOCIAL SECURITY ADMINISTRATION

MEDICAL REPORT (General)

(d)(1)

PRIVACY ACT: The Social Security Administration is authorized to collect the information on this form under sections 205(a), 223(d), (5)(A),
1614(a)(3)(H)(i) and 1631(e)(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 of information between Social Security and another agency.
Computer Matching Statement: We may also use the information you give us when we match records by computer. Matching programs compare our
records with those of other Federal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies
for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. 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 30 minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO THE OFFICE THAT REQUESTED IT. If you do not know the address, you may call Social Security at
1-800-772-1213. You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send
only comments relating to our time estimate to this address, not the completed form.

Identifying
Information
(To be completed by
Requesting
Office)

PATIENT'S NAME

DATE OF BIRTH

SOCIAL SECURITY NO.

WAGE EARNER'S NAME (if different from patient)

NAME AND ADDRESS OF REQUESTING OFFICE

-

NAME OF DOCTOR

-

Medical Source

NOTICE TO PHYSICIAN: Medical Source
PLEASE INCLUDE SUFFICIENT DETAILS OF HISTORY, PHYSICAL AND DIAGNOSTIC FINDINGS, CLINICAL COURSE,
THERAPY AND RESPONSE TO ENABLE A REVIEWING PHYSICIAN TO MAKE AN INDEPENDENT DETERMINATION
AS TO THE SEVERITY AND DURATION OF THE IMPAIRMENT. Medical Consultant
I.

HISTORY:

DATE YOU FIRST EXAMINED PATIENT

DATE OF MOST RECENT EXAMINATION

FREQUENCY OF VISITS

Form SSA-3826-F4 (6-2006) ef (6-2006)

1

Medical
II. PHYSICAL FINDINGS: Please show all pertinent findings (with dates).
HEIGHT

WEIGHT

Form SSA-3826-F4 (6-2006) ef (6-2006)

2

Ill. LABORATORY AND SPECIAL STUDIES: Give Results of all Pertinent Studies With Dates. (In the case of ECG's and PFSs
please attach a copy of the tracing or a detailed description thereof.)

Form SSA-3826-F4 (6-2006) ef (6-2006)

3

IV. DIAGNOSES:
1.
2.
3.

V. TREATMENT and RESPONSE

VI. ABILITY TO MANAGE FUNDS COMPLETE IF MENTAL DIAGNOSIS
In your opinion, is the patient able to manage his/her own funds?

REPORTING PHYSICIAN'S NAME AND ADDRESS (Type or Print)

YES

SIGNATURE

TITLE

TELEPHONE NUMBER (Include area code)

DATE

Medical Source's

Form SSA-3826-F4 (6-2006) ef (6-2006)

4

NO (Explain)