Form SSA-454-BK Continuing Disability Review Report

CONTINUING DISABILITY REVIEW REPORT
SSA-454-BK
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The office that reviews your medical condition will use the information in this report. The
information will help that office decide whether you are still disabled. Please complete as much of
the report as you can.
IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask your
health care provider to complete this report. If you cannot complete the report, a Social Security
Representative will assist you. If you have an appointment, please have the completed report
ready when we contact you.

Note: If you are assisting someone else with this report, please answer the questions as if that
person were completing the report.
HOW TO COMPLETE THIS REPORT

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•

•

•
•

Print or write clearly.
Include a ZIP or postal code with each address.
Provide complete phone numbers, including area code. If a phone number is outside the
United States, provide International Direct Dialing (IDD) code and country code.
If you cannot remember the names and addresses of your health care providers, you may be
able to get that information from the telephone book, Internet, medical bills, prescriptions, or
prescription medicine containers.
ANSWER EVERY QUESTION, unless the report indicates otherwise. If you do not know an
answer, or the answer is "none" or "does not apply," please write: "don't know," or "none," or
"does not apply."
Be sure to explain an answer if the question asks for an explanation or if you want to give
additional information.
If you need more space to answer any question, please use Section 11 - Remarks, on the
last page to finish your answer. Write the number of the question you are answering.
YOUR MEDICAL RECORDS

If you have any of your medical records covering the last 12 months, send or bring them to our
office with this completed report. Please tell us if you want to keep your records so we can return
them to you. If you have a scheduled appointment for an interview, bring your medical records,
your prescription medicine containers (if available), and the completed report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS
THAT YOU DO NOT ALREADY HAVE. With your permission, we will request your records. The
information that you give us on this report tells us where to request your medical and other
records.

Form SSA-454-BK (07-2010) ef (07-2010) Destroy prior editions

The Privacy Act

See Revised Privacy Act Statement

Sections 205(a), 223(d), and 1631(e) (1) of the Social Security Act, as amended, authorize us
to collect this information. The information you provide will be used to make a decision on the
named claimant's claim. While giving us the information on this report is voluntary, failure to
provide all or part of the requested information could prevent an accurate or timely decision on
the named claimant's claim. We generally use the information you supply for the purpose of
making decisions regarding claims. 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 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 about Social Security records (e.g., to the Government
Accountability Office and the 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.socialsecurity.gov or at any local Social Security office.

The Paperwork Reduction Act See Revised PRA
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 60 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
Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time estimate
to this address, not the completed report.
SEND OR BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL SECURITY
OFFICE, THE NEAREST U.S EMBASSY OR CONSULATE OFFICE. Office addresses are
listed under U.S. Government agencies in your telephone directory or you may call
1-800-772-1213 (TTY 1-800-325-0778) for the address.

AFTER COMPLETING THIS FORM, REMOVE THIS SHEET AND KEEP IT FOR YOUR RECORDS.

Form SSA-454-BK (07-2010) ef (07-2010)

Form Approved
OMB No. 0960-0072

SOCIAL SECURITY ADMINISTRATION

CONTINUING DISABILITY REVIEW REPORT
For SSA Use Only -

Do not write in this box.

Date of your last medical disability decision:

Claim Number:

Number Holder

Type(s) of Case(s):
(Check all that apply.)

TITLE II
TITLE XVI

DIB

DWB

CDB

FZ

ESRD

HIB

DI

DS

DC

BI

BS

BC

If you are filling out this report for the disabled person, please provide information about him
or her. When a question refers to "you", "your", or the "disabled person", it refers to the
person receiving disability benefits.

SECTION 1- INFORMATION ABOUT THE DISABLED PERSON
1.B. SOCIAL SECURITY NUMBER

1.A. NAME (first, middle initial, last)

-

-

1.C. MAILING ADDRESS (Street or P O Box) Include apartment number if applicable
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

1.D. DAYTIME PHONE NUMBER including area code, and the IDD and country codes if you live outside the
USA or Canada.
Phone number
Check this box if you have a phone or a number where we can leave a message

1.E. Alternate Phone Number, including area code where we
may reach you, if any
Alternate phone number

1.F. Can you speak and understand English?

YES

NO

If no, what language do you prefer?
If you cannot speak and understand English, we will provide an interpreter, free of charge.
1.G. Have you used any other names on your medical or educational records in the last 12 months?
Examples are maiden name, other married names, or nickname.
YES
NO
If yes, please list them here

SECTION 2 - CONTACTS
Give the name of a friend or relative (other than your doctors) we can contact who knows about your
medical conditions, and can help you with your case.
2.B. Relationship to Disabled Person
2.A. NAME (first, middle initial, last)
2.C. MAILING ADDRESS (Street or P O Box) Include apartment number if applicable
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

2.D. DAYTIME PHONE NUMBER (as described in 1.D. above)
2.E. Can this person speak and understand English?
If no, what language is preferred?
Form SSA-454-BK (07-2010) ef (07-2010)

YES

NO
PAGE 1

SECTION 2 - CONTACTS (continued)
2.F. Who is completing this report?
The disabled person listed in 1.A (Go to Section 3 - Medical Conditions)
The person listed in 2.A (Go to Section 3 - Medical Conditions)
Someone else (Complete the rest of Section 2 below)

2.G. NAME (first, middle initial, last)

2.H. Relationship to Disabled Person

2.I. DAYTIME PHONE NUMBER (as described in 1.D. above)
2.J. MAILING ADDRESS (Street or P O Box) Include apartment number if applicable
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

SECTION 3 - MEDICAL CONDITION(S)
3.A. If you are an adult (age 18 or older), list the physical and/or mental condition(s) (including emotional or
learning problems) that limit your ability to work. If you are completing this report for a child (under age 18),
list the physical and/or mental condition(s) (including emotional and learning problems) that limit the child's
ability to do the same things as other children the same age. List each physical and/or mental condition
separately.
1.
2.
3.
4.
If you need more space go to Section 11 - Remarks on last page
3.B. What is your height without shoes?

OR
feet

3.C. What is your weight without shoes?

inches

centimeters (if outside USA)
OR

pounds

kilograms (if outside USA)

SECTION 4 - WORK
Complete only if you are age 14 years old or older
4. Since the date of your last medical disability decision have you worked? (see date at top of Page 1)
YES (If yes, we may contact you for additional information)
NO

SECTION 5 - MEDICAL TREATMENT
Within the last 12 months, have you seen a doctor or other health care professional or received treatment at a
hospital or clinic, or do you have a future appointment scheduled:
5.A. For any physical conditions?
YES

NO

5.B. For any mental condition(s) (including emotional or learning problems)
YES

NO

If you answered "No" to both 5.A. and 5.B., go to Section 6 - Other Medical Information on page 8
Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 2

SECTION 5 - MEDICAL TREATMENT (continued)
5.C. Tell us who may have medical records covering the last 12 months about any of your physical or mental
condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you have
one scheduled.
Name of facility or office

Name of health care professional that treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROFESSIONAL ABOVE.
PHONE

(

)

PATIENT ID# (if known)

-

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient visits
First Visit

2. Emergency Room Visits
List the most recent date first

3. Overnight Hospitals Stays

A.

A. Date in

Date out

B.

B. Date in

Date out

C.

C. Date in

Date out

Last Visit
Next Scheduled Appointment (if any)

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in the box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or has
scheduled you to take. Please give the dates for past and future tests. If you need to list more tests, use
Section 11 - Remarks on the last page.
Check this box if no tests by this provider or at this facility.
KIND OF TEST

DATES OF TESTs

KIND OF TEST

EKG (heart test)

EEG (brain wave test)

Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)

HIV Test
Blood Test (not HIV)
X-Ray (list body part)

Hearing Test

MRI/CT Scan (list body part)

DATES OF TESTs

Speech/Language Test
Vision Test

Other (please describe)

Breathing Test

If you do not have any more doctors or hospitals to describe, go to Section 6 on page 8.
Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 3

SECTION 5 - MEDICAL TREATMENT (continued)
5.D. Tell us who may have medical records covering the last 12 months about any of your physical or mental
condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you have
one scheduled.
Name of facility or office

Name of health care professional that treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROFESSIONAL ABOVE.
PHONE

(

)

PATIENT ID# (if known)

-

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient visits
First Visit

2. Emergency Room Visits
List the most recent date first

3. Overnight Hospitals Stays

A.

A. Date in

Date out

B.

B. Date in

Date out

C.

C. Date in

Date out

Last Visit
Next Scheduled Appointment (if any)

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in the box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or has
scheduled you to take. Please give the dates for past and future tests. If you need to list more tests, use
Section 11 - Remarks on the last page.
Check this box if no tests by this provider or at this facility.

KIND OF TEST

DATES OF TESTs

KIND OF TEST

EKG (heart test)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing Test
Speech/Language Test

MRI/CT Scan (list body part)

Vision Test

Other (please describe)

DATES OF TESTs

Breathing Test

If you do not have any more doctors or hospitals to describe, go to Section 6 on page 8.
Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 4

SECTION 5 - MEDICAL TREATMENT (continued)
5.E. Tell us who may have medical records covering the last 12 months about any of your physical or mental
condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you have
one scheduled.
Name of facility or office

Name of health care professional that treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROFESSIONAL ABOVE.
PHONE

(

)

PATIENT ID# (if known)

-

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient visits
First Visit

2. Emergency Room Visits
List the most recent date first

3. Overnight Hospitals Stays

A.

A. Date in

Date out

B.

B. Date in

Date out

C.

C. Date in

Date out

Last Visit
Next Scheduled Appointment (if any)

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in the box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or has
scheduled you to take. Please give the dates for past and future tests. If you need to list more tests, use
Section 11 - Remarks on the last page.
Check this box if no tests by this provider or at this facility.

KIND OF TEST

DATES OF TESTs

KIND OF TEST

EKG (heart test)
Treadmill (exercise test)

EEG (brain wave test)
HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing Test

MRI/CT Scan (list body part)

DATES OF TESTs

Speech/Language Test
Vision Test

Other (please describe)

Breathing Test

If you do not have any more doctors or hospitals to describe, go to Section 6 on page 8.
Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 5

SECTION 5 - MEDICAL TREATMENT (continued)
5.F. Tell us who may have medical records covering the last 12 months about any of your physical or mental
condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you have
one scheduled.
Name of facility or office

Name of health care professional that treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROFESSIONAL ABOVE.
PHONE

(

)

PATIENT ID# (if known)

-

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient visits
First Visit

2. Emergency Room Visits
List the most recent date first

3. Overnight Hospitals Stays

A.

A. Date in

Date out

B.

B. Date in

Date out

C.

C. Date in

Date out

Last Visit
Next Scheduled Appointment (if any)

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in the box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or has
scheduled you to take. Please give the dates for past and future tests. If you need to list more tests, use
Section 11 - Remarks on the last page.
Check this box if no tests by this provider or at this facility.

KIND OF TEST

DATES OF TESTs

KIND OF TEST

EKG (heart test)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing Test

MRI/CT Scan (list body part)

DATES OF TESTs

Speech/Language Test
Vision Test

Other (please describe)

Breathing Test

If you do not have any more doctors or hospitals to describe, go to Section 6 on page 8.
Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 6

SECTION 5 - MEDICAL TREATMENT (continued)
5.G. Tell us who may have medical records covering the last 12 months about any of your physical or mental
condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you have
one scheduled.
Name of facility or office

Name of health care professional that treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROFESSIONAL ABOVE.
PHONE

(

)

PATIENT ID# (if known)

-

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient visits
First Visit

2. Emergency Room Visits
List the most recent date first

3. Overnight Hospitals Stays

A.

A. Date in

Date out

B.

B. Date in

Date out

C.

C. Date in

Date out

Last Visit
Next Scheduled Appointment (if any)

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in the box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or has
scheduled you to take. Please give the dates for past and future tests. If you need to list more tests, use
Section 11 - Remarks on the last page.
Check this box if no tests by this provider or at this facility.

KIND OF TEST

DATES OF TESTs

KIND OF TEST

EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization

EEG (brain wave test)
HIV Test

Biopsy (list body part)

X-Ray (list body part)

Hearing Test

DATES OF TESTs

Blood Test (not HIV)

MRI/CT Scan (list body part)

Speech/Language Test
Vision Test

Other (please describe)

Breathing Test

If you do not have any more doctors or hospitals to describe, go to Section 6 on page 8.
Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 7

If you are under age 18, Skip to Section 11 - Remarks on the last page.

SECTION 6 - OTHER MEDICAL INFORMATION
Complete only if you are age 18 years old or older
6. Does anyone else have medical information about your physical or mental condition(s) (including emotional
and learning problems) covering the last 12 months, or are you scheduled to see anyone else? (This may
include places such as workers' compensation, vocational rehabilitation, insurance companies who have paid
you disability benefits, prisons, atttorneys, social service agencies and welfare.)
YES (Complete the following information.)
NO (Go to SECTION 7.)
NAME OF ORGANIZATION

PHONE NUMBER

(

)

-

MAILING ADDRESS

STATE/Province

CITY

NAME OF CONTACT PERSON

Date First Contact (in last 12 months)

ZIP/Postal Code

COUNTRY (if not USA)

CLAIM NUMBER (if any)

Date Last Contact (in last 12 months)

Date Next Contact (if any)

Reasons for Contacts
If you need to list other people or organizations use Section 11 - Remarks on the last page and give the
same detailed information as above for each one you list.

SECTION 7 - MEDICINES
7. Are you now taking, or have you taken in the last 12 months, any prescription or non-prescription
medicines?
YES (Complete the following information. Look at your medicine containers, if
NO (Go to SECTION 8.)

NAME OF MEDICINE

IF PRESCRIBED, GIVE
NAME OF DOCTOR

REASON FOR
MEDICINE

If you need to list other medicines use Section 11 - Remarks on the last page
Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 8

SECTION 8 - EDUCATION AND TRAINING
Complete only if you are age 18 years old or older
8.A. Have you received any education since your last disability decision? (See date at top of Page 1.)

YES (Complete the information below.)

NO, go to question 8.B below

If Yes, what year did you last attend any school?
Please describe the education you received.
8.B. Have you received any type of specialized job, trade, or vocational training since your last disability
decision? (See date at top of Page 1.)
YES (Complete the information below.)

NO

PHONE

NAME OF TRAINING FACILITY

(

)

-

MAILING ADDRESS
STATE/Province

CITY
TYPE OF PROGRAM

ZIP/Postal Code

COUNTRY (if not USA)

Date Completed (or scheduled to be completed)

If you need to list other education information or training facilities use Section 11 - Remarks on the last
page and give the same detailed information as above

SECTION 9 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT
SERVICES
Complete only if you are age 18 years old or older
9.A. Since the date of your last medical disability decision (see date on top of Page 1), have you
participated, or are you participating, in:
• an individualized work plan with an employment network under the Ticket to Work Progam;
• an individualized plan for employment with a vocational rehabilitation agency or any other organization;
• a Plan to Achieve Self-Support (PASS);
• an Individualized Education Program (IEP) through a school (if a student age 18-21); or
• any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?
NO (Go to Section 10)
YES (Complete the information below.)
NAME OF ORGANIZATION OR SCHOOL
NAME OF COUNSELOR, INSTRUCTOR, OR JOB COACH

PHONE NUMBER

(

)

-

MAILING ADDRESS

CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

9.B. When did you start participating in the plan or program?
Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 9

SECTION 9 - VOCATIONAL REHABILITATION, EMPLOYMENT, or OTHER SUPPORT
SERVICES (continued)
Complete if you are age 18 years old or older
9.C. Are you still participating in the plan or program?
YES, I am scheduled to complete the plan or program on:
(date to be completed)

NO, I completed the plan on:
(date completed)

NO, I stopped participating in the plan before completing it because:

9.D. What types of services, tests, or evaluations were provided (for example: intelligence or psychological
testing, vision or hearing test, physical exam, work evaluations, or classes?)

If you need to list another plan or program use Section 11 - Remarks on the last page and give the same
detailed information as above

SECTION 10 - DAILY ACTIVITIES
Complete only if you are age 18 years old or older
10.A. Describe what you do in a typical day (for example: I get up around 7 A.M., take a shower, eat breakfast,
etc.).

If you need more space, go to Section 11 - Remarks on the last page
10.B. Do you use an assistive device (for example: eye glasses, hearing aids, braces, canes, crutch(es),
walker, wheelchair, service animal)?
Sometimes
Never
Always
If ALWAYS OR SOMETIMES, please describe what kind, when, and how you use it.

If you need more space, use SECTION 11 - Remarks on the last page
10.C. Do you have hobbies or interests?
NO
YES
If YES, please decribe what they are and how much time you spend doing them.

If you need more space, use Section 11 - Remarks on the last page
Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 10

SECTION 10 - DAILY ACTIVITIES (continued)
Complete only if you are age 18 years old or older
10.D. Do you ever have difficulty doing any of the following? (Please explain any "Yes" answers.)
Dressing

Yes

No

Bathing

Yes

No

Caring for hair

Yes

No

Taking medicines

Yes

No

Preparing meals

Yes

No

Feeding self

Yes

No

Doing chores (inside/outside house)

Yes

No

Driving or using public transportation

Yes

No

Shopping

Yes

No

Managing money

Yes

No

Walking

Yes

No

Standing

Yes

No

Lifting objects

Yes

No

Using arms

Yes

No

Using hands or fingers

Yes

No

Sitting

Yes

No

Seeing, hearing, or speaking

Yes

No

Concentrating

Yes

No

Remembering

Yes

No

Understanding or following directions

Yes

No

Completing tasks

Yes

No

Getting along with people

Yes

No

Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 11

SECTION 11 - REMARKS
Please write any additional information you did not give in earlier parts of this report. If you did not have enough
space in the sections of this report to write the requested information, please use this space to tell us the
additional information requested in those sections. Be sure to show the section to which you are referring.

Date Report Completed (month, day, year)
Form SSA-454-BK (07-2010) ef (07-2010)

PAGE 12

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to make a decision on the
named claimant’s claim. Furnishing us this information is voluntary. However, failing to
provide us with all or part of the information could prevent an accurate or timely decision on the
named claimant’s claim.
We rarely use the information you supply for any purpose other than to make a decision on the
named claimant’s claim. However, we may use the information for the administration of our
programs including sharing information:
1. 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);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of our programs. (e.g., to the Bureau of Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices entitled, Supplemental Security Income
Record and Special Veterans Benefits (60-0103), Claims Folders System (60-0089), Master
Beneficiary Record (60-0090), and Electronic Disability Claim File (60-0320). Additional
information about this and other system of records notices and our programs are available from
our Internet website at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.

SSA will insert the following revised PRA Statement 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 (OMB) control number. We estimate that it will take about
60 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 21235-0001.