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Form HA-4631 |
Claimant's Recent Medical TreatmentWhen you have requested, or are requesting, a hearing before an Administrative Law Judge (ALJ), use this form to tell us about medical treatment you have received since you, or someone on your behalf (for example, your representative or doctor), last furnished medical information to us. If you are not certain whether you told us about treatment you have received, or remember treatment that you forgot to tell us about, include that information, also. How to Obtain the FormBelow you will find Form in Portable Document Format (PDF). To print the PDF version, you will need the Adobe Acrobat reader software. If you do not already have this special software, see our page on downloading and printing PDF documents.After you download the Adobe Acrobat Reader, come back to this page and download the PDF version of the HA-4631: Claimant's Recent Medical Treatment, HA-4631 How to Complete the FormCLAIMANT and SOCIAL SECURITY NUMBER: Enter your name and Social Security number (SSN) or, if you are not the claimant, the name and SSN of the person on whose behalf the request for hearing was filed.WAGE EARNER: If you receive or are applying for Social Security benefits on someone else's work record, enter that person's name and SSN. The last time we brought your case up-to-date was: Enter the date you last provided medical information to us. In the rest of the form, tell us about the medical treatment that you have received since you last gave us information about your medical treatment.
If you need more space, use additional sheets of paper. Include your name and SSN on any additional pages, and on all correspondence, you send to us. EVIDENCE: If you have any evidence that we did not have when we made the reconsideration determination, please include it when you send this form to us. You must send a signed medical release form for each of the medical sources you list, see SSA-827, Authorization to Disclose Information to the Social Security Administration. To ensure that we have current information, you should also complete an HA-4632, Claimant's Medications. If you have worked since you filed your application for disability benefits, complete an HA-4633, Claimant's Work Background. |
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Send the Form |
Where To Send The FormPrint the PDF HA-4631 form on 8 1/2 x 11 inch paper, complete the form, and mail it to the hearing office where your claim is located. The address and telephone number of the hearing office are on the letter acknowledging receipt of the request for hearing that we sent. |
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