Form HA-4632 Claimant's Medications

Form Approved
OMB No.0960-0289

SOCIAL SECURITY ADMINISTRATION
Office of Disability Adjudication and Review

CLAIMANT'S MEDICATIONS
A. To be completed by Hearing Office
(Claimant and Social Security Number)

(Wage Earner and Social Security Number) The last time we brought your case
(Leave blank if same as claimant)
up-to-date was:

B. To be completed by the claimant

PLEASE PRINT
PLEASE LIST BELOW THE PRESCRIPTION MEDICATION WHICH YOU ARE PRESENTLY TAKING. IF THE
NAME OF THE MEDICATION IS NOT SHOWN ON THE PRESCRIPTION CONTAINER, YOU MAY VERIFY THE
NAME WITH YOUR PHARMACIST.
NAME OF
DATE FIRST
DAILY
REASONS FOR MEDICATION
NAME OF
MEDICATION & PRESCRIBED
AMOUNT
PHYSICIAN
DOSAGE
TAKEN

PLEASE LIST BELOW THE NONPRESCRIPTION MEDICATION YOU ARE TAKING AND THE REASONS YOU TAKE THEM.

Form HA-4632 (2-1994) ef (6-2009)
Use Until Stock Is Exhausted

If more space is needed,
use additional sheets.

Privacy Act Statement
See Revised
Privacy Act
Statement
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.
Collection and Use of Personal Information

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.
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 control
number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed
form.
Form HA-4632 (2-1994) ef (6-2009)

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, 223, 702, 1614, 1631, and 1869 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 re-evaluating the decision on your claim.
We will use the information to determine your eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•

To representative payees, when the information pertains to individuals for whom they serve
as representative payees, for the purpose of assisting the Social Security Administration in
administering its representative payment responsibilities under the Act and assisting the
representative payees in performing their duties as payees, including receiving and
accounting for benefits for individuals for whom they serve as payees; and

•

To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representatives or representative payees to the extent necessary to pursue
Social Security claims and to representative payees when the information pertains to
individuals for whom they serve as representative payees, for the purpose of assisting SSA in
administering its representative payment responsibilities under the Act and assisting the
representative payees in performing their duties as payees, including receiving and
accounting for benefits for individuals for whom they serve as payees.

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 two of our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784 and 60-0103, entitled Supplemental Security Income Record and
Special Veterans Benefits as published in the FR on January 11, 2006, at 71 FR 1830.
Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.