Claimant's Medication - PDF/Paper Version

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), 702, 1631(e), 1614(a), and 1869(b)(1) of the Social Security Act, as
amended, and 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations authorize us to
collect this information. We will use the information you provide to determine your eligibility
for disability benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from re-evaluating the decision on your claim.
We rarely use the information you supply for any purpose other than what we state above,
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);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census
and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our System of Records Notice, 60-0089, entitled Claims Folders Systems. 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 agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State,
or local government agencies. We can use the information from these matching programs 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.