Form HA-4631 CLAIMANT'S RECENT MEDICAL TREATMENT

Social Security Administration

Form Approved
OMB No.0960-0292

Office of Disability Adjudication and Review

CLAIMANT’S RECENT MEDICAL TREATMENT
A. To be completed by Hearing Office staff
Claimant’s Name:

SSN:

The last time your case was brought up-to-date:

B. To be completed by claimant

Please Answer the Following Questions:
1) Have you been treated or examined by a doctor (other than a doctor at a hospital) since the above date?

Yes

No

(List the names and addresses of doctors who have treated or examined you since the above date and the dates of treatment
or examination. If possible, you should submit an updated report from these doctors to the Administrative Law Judge prior
to the date of your hearing.)
DOCTORS’ NAME(S)
ADDRESS(ES)
DATE(S)

2) What have these doctors told you about your condition?

Yes
No
3) Have you been hospitalized since the above date?
(If so, please state the name and address of the hospital, the reasons why you were hospitalized and the nature of the
treatment you received.)
Name of Hospital
Address of Hospital (include ZIP code)

If more space is needed use the back of the form
PLEASE READ THE PRIVACY ACT
STATEMENT ON THE NEXT PAGE
Form HA-4631 (8-1996) ef (10-2004)
Issue Old Stock

PRIVACY ACT AND PAPERWORK ACT NOTICE
The Social Security Act (sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (C), as
appropriate) authorizes the collection of information on this form. We will use the information
on your recent medical treatment to help us decide if we need to obtain more information. You
do not have to give it, but if you do not you may not receive benefits under the Social Security
Act. We may give out the information on this form without your written consent if we need to
get more information to decide if you are eligible for benefits or if a Federal law requires us to
do so. Specifically, we may provide information to another Federal, State, or local government
agency which is deciding your eligibility for a government benefit or program; to the President
or a Congressman inquiring on your behalf; to an independent party who needs statistical
information for a research paper or audit report on a Social Security program; or to the
Department of Justice to represent the Federal Government in a court suit related to a program
administered by the Social Security Administration.
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 you provide us 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.
See Revised Privacy Act Statement
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 10 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.
See Revised Paperwork
Reduction Statement

Form HA-4631 (8-1996) ef (5-2004)

The following revised Privacy Act Statement will be inserted into the form
at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (C) of the Social
Security Act, as amended, authorize us to collect this information. The information you
provide will be used to determine whether we need to obtain additional information
regarding your treatments or conditions.
The information you furnish on this form is voluntary. However, failure to provide the
requested information may prevent you from receiving benefits under the Social Security
Act.
We generally use the information you supply for the purpose of determining eligibility
for benefits. 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
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs 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 person’s eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 10
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
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.