Form SSA-199 Vocational Rehabilitation Provider Claim

FORM APPROVED
OMB No. 0960-0310

SOCIAL SECURITY ADMINISTRATION

VOCATIONAL REHABILITATION PROVIDER CLAIM
To:

From:
Social Security Administration
Office of Employment Support Programs
VRA Operations Team
P.O. Box 17714
Baltimore, Maryland 21235-7714
VR Provider
Code

Check One

Claim Based On:

Continuous Period of SGA

Medical Recovery during VR

If claim is based upon other than a continuous period of SGA, it is not necessary to complete items 6, 8, 9, or 13 below.
Check One

Initial Claim

Reconsideration

Resubmittal

Supplemental

1. Client (First Name, MI, Last Name)

2.

SSA

3. SSN (Widow or child, if appropriate) 4.

SSN (Primary)

Blind
Non-Blind

SSI
5a. Date Client Entered 5b. Date Signed IPE
VR OO

6. Date Employment Began

7. Date of Final VR
Closure

8. Months Work Activity Tracked After VR
Closing (show months)

9. Medical services were provided, initiated, or coordinated under IWRP
10. Claim based solely on extended evaluation services (VR 06)
11. Direct cost during VR (after 9/30/81) -- Total from Item 17d (over)

$

12. Administrative, counseling and placement costs during VR (after 9/30/81)

$

13. Administrative costs only for tracking after VR (after 9/30/81)

$

14. Other (identify in Remarks section below)

$

15. Total amount claimed

$

Yes

No

Yes

No

16. What type of occupation(s) did the client perform during the continuous period of SGA:

Remarks:

Signature

Title

Form SSA-199 (03-2010) EF (03-2010)
Destroy prior editions

CONTINUED ON REVERSE SIDE

Date

17. Itemization of direct cost services provided during the period of VR (after 9/30/81):
(Use additional sheets as needed)
17a.

17c

17b.
Date of Service

Type of Service

Cost of Service

#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#1
1
#12
#13
#14
#15
17d. Total of column 17c (also enter in item 11 - over)

$

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1633(a) of the Social Security Act authorize us to collect this information. The information you provide us on this form will
be used to make claim determinations.
See Revised Privacy Act Statement Attached
Completion of this form is voluntary, however, we cannot make a payment unless you make the required claims information available to us
using this form or another mutually agreed upon method for submitting a claim.
We rarely use this information you supply for any purpose other than for deciding on a claim. 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 audit or investigate 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.socialsecurity.gov or at your local 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 23 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

www.socialsecurity.gov/work
Form SSA-199 (03-2010) EF (03-2010)

PRIVACY ACT STATEMENT
Vocational Rehabilitation Provider Claim

Sections 205(a), 222(d), and 1615(d) of the Social Security Act, as amended, authorize us to
collect this information. We will use this information to determine claim eligibility.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from making an accurate and timely decision on the claim
determination.
We rarely use the information for any purpose other than for making a decision regarding claim
entitlements. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose the 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 us in establishing rights to Social Security
benefits and coverage;
2. To comply with Federal laws requiring the release of information from our 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, and investigatory activities necessary to assure the
integrity and improvement 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 and administered benefit programs and for repayment of
payment’s or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act Systems of
Records Notice entitled, Vocational Rehabilitation Reimbursement Case Processing System,
60-0221. This notice, additional information regarding our programs and systems are available
on-line at www.socialsecurity.gov or at your local Social Security office.