OMB control number
Request for Evidence from Doctor or Hospital
OMB 0960-0722 ยท SSA.
OMB 0960-0722
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 2026-07-31 and is listed under ICR 202011-0960-003.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form HA-66 Request for Medical Evidence From a Doctor | Form and Instruction |
| Form HA-67 Request for Medical Evidence From a Hospital | Form and Instruction |
 Supporting Statement - 0757 (Final).docx | Supporting Statement A |
| Addendum 0960-0722.docx | Supplementary Document |
 HA-66 with Medical Source Information - paper submission |
Form and Instruction |
| HA-67 with Medical Source Information - electronic submission |
Other-Internet Screen |
| HA-67 with Medical Source Information - paper submission |
Form and Instruction |
| HA-66 with Medical Source Information - electronic submission |
Other-Internet Screen |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202605-0960-001 | Revision of a currently approved collection | 2026-05-27 | ||
| 202011-0960-003 | Revision of a currently approved collection | 2020-11-06 | ||
| 201703-0960-014 | Revision of a currently approved collection | 2017-07-11 | Approved without change | |
| 201402-0960-004 | Extension without change of a currently approved collection | 2014-05-28 | Approved without change | |
| 201009-0960-004 | Revision of a currently approved collection | 2011-03-31 | Approved without change | |
| 200708-0960-005 | Revision of a currently approved collection | 2008-03-13 | Approved without change | |
| 200603-0960-009 | Existing collection in use without an OMB Control Number | 2006-03-21 | Approved without change |
OMB Details
HA-66 with Medical Source Information - paper submission
Federal Enterprise Architecture: Income Security - General Retirement and Disability
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form HA-66 | Request for Medical Evidence From a Doctor | Paper Only | Form and instruction |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.