Request for Evidence from Doctor or Hospital

Sections 223(d)(5) and 1614(a)(3)(H)(i) of the Social Security Act require claimants to furnish medical evidence of their disability when filing a disability claim. SSA uses Forms HA-66 and HA-67 to obtain medical evidence from medical sources identified by the claimants as having information relative to their impairments or ability to do work-related activities. In addition to accepting manual paper responses, SSA sends a barcode with the HA-66 and HA-67 allowing respondents to fax the information directly into the electronic claims folder rather than submitting it manually. SSA uses the information to determine eligibility for benefits. The respondents are medical sources, doctors, and hospitals that evaluate the claimants.

The latest form for Request for Evidence from Doctor or Hospital expires 2021-01-31 and can be found here.

HA-66 with Medical Source Information - paper submission

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.