Claimant's Recent Medical Treatment

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), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (C) 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 an accurate and timely
decision on any claim filed or could result in denial of the claim.
We will use the information to determine eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
1. To third party contacts in situations where the party to be contacted has, or is expected to
have, information relating to the individual’s capability to manage his or her affairs or his
or her eligibility for or entitlement to benefits under the Social Security program when
the data are needed to establish the validity of evidence or to verify the accuracy of
information presented by the individual, and it concerns his or her eligibility for benefits
under the Social Security program; and
2. To specified business and other community members and Federal, State, and local
agencies for verification of eligibility for benefits under section 1631(e) of the Act.
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 Notices
(SORN) 60-0089, entitled Claims Folders System, and 60-0320, entitled Electronic Disability
(eDIB) Claim File. Additional information and a full listing of all our SORNs are available on
our website at www.ssa.gov/privacy/sorn.html.