(2) What have these doctors told you about your condition?
Have you been treated or examined by a doctor (other than a doctor at a hospital)
since the above date?
Have you been hospitalized since the above date?
(Wage Earner and Social Security Number)
(Leave blank if same as claimant)
Treatment received:
Reason for hospitalization:
(Claimant and Social Security Number)
The last time we brought
your case up-to-date was:
CLAIMANT'S RECENT MEDICAL TREATMENT
Form Approved
OMB No. 0960-0292
A. To be completed by hearing office
- -
- -
PLEASE PRINT
B. To be completed by the claimant
Please Answer the Following Questions:
(1)
ADDRESS(ES) & TELEPHONE NO.(S)
DATE(S)
DOCTORS NAME(S)
(3)
(If yes, please list the name and address of the hospital. Also, explain why you were hospitalized and what treatment you
received.)
Name of Hospital
Address of Hospital (Include ZIP Code)
(If yes, please list the names, addresses and telephone numbers of doctors who have treated or examined you since the above
date. Also list the dates of treatment or examination. If possible, send updated reports from these doctors to the Administrative
Law Judge before the date of your hearing.)
Social Security Administration
Office of Hearings and Appeals
U
U
Yes
No
If more space is needed,
use additional sheets.
Form HA-4631 (8-1996) ef (10-2004)
Issue Old Stock
Yes
No
PRIVACY ACT AND PAPERWORK ACT NOTICE
The Social Security Act (sections 205(a), 702, 1631 (e)(1)(A) and (B), and 1869(b)(1) and (C), as
appropriate) authorizes the collection of information on this form. We will use the information on your
medical treatment to help us decide if we need to obtain more information. You do not have to give it,
but if you do not you may not receive benefits under the Social Security Act. We may give out the
information on this form without your written consent, if we need to get more information to decide if
you are eligible for benefits or if a Federal law requires us to do so. Specifically, we may provide
information to another Federal, State, or l