Medical Source Statement of Ability to Do Work-Related Activities (Mental)

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d), 1614(a) and 1631(d) of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent us from making an accurate and timely
decision on the named claimant’s eligibility for benefits.
We will use the information to make a determination of eligibility for benefits. We may also
share your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies for administering cash or non-cash income
maintenance or health maintenance programs; and
2. To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for the Social Security
Administration (SSA) as authorized by law, and they need access to personally
identifiable information in SSA records in order to perform their assigned agency
functions.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0089, entitled Claims Folders Systems. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.