Information Collection

Claimant's Recent Medical Treatment

IC 9198 under ICR 201801-0960-004 · OMB 0960-0292.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0292 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-4631 Claimant's Recent Medical Treatment	Form
HA-4631 - Revised PA Statement.pdf www.ssa.gov	Other-Revised Privacy Act Statement
HA-4631 Claimant's Recent Medical Treatment HA-4631 - Revised Version.pdf www.ssa.gov/online/ha-4631.html.	Form
HA-4631 - Current Version.pdf HA-4631 Current Version	IC Document

IC Title:

Claimant's Recent Medical Treatment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1512 20 CFR 416.912

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-4631	Claimant's Recent Medical Treatment	HA-4631 - Revised Version.pdf	http://www.ssa.gov/online/ha-4631.html.	Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act Statement			HA-4631 - Revised PA Statement.pdf	www.ssa.gov	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	200,000	200,000
Annual IC Time Burden (Hours)	33,333	33,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HA-4631 Current Version	HA-4631 - Current Version.pdf	04/10/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.