The last time we brought
your case up-to-date was:
OMB No. 0960-0289
To be completed by Hearing Office
To be completed by the claimant
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
REASON FOR MEDICATION
If more space is needed,
use additional sheets.
FORM HA-4632 (2-1994) ef (10-2004)
Use Until Stock Is Exhausted
(Claimant and Social Security Number)
PLEASE LIST BELOW THE NONPRESCRIPTION MEDICATION YOU ARE TAKING AND THE REASONS YOU TAKE THEM.
(Wage Earner and Social Security Number)
(Leave blank if same as claimant)
SOCIAL SECURITY ADMINISTRATION
Office of Hearings and Appeals
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 work background 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 local
government agency which is deciding your eligibility for a government benefit or program; to
the President or Congressman inquiring on your behalf; to an independent party who needs
statistical information for a research paper or audit report on a Social Security program; or to the
Department of Justice to represent the Federal Government in a court suit related to a program
administered by the Social Security Administration.
We may also use the informatio