This report is used to update your information for your disability appeal. Completing this report accurately helps us process your claim. Please complete as much of this report as you can.
IF YOU NEED HELP
Please do not ask your health care provider to complete this report. You can get help from other people,such as a friend or family member. If you cannot complete this report, a Social Security representative can assist you. If you make an appointment with us, please complete as much of this report as you can and have it with you for your appointment.
HOW TO COMPLETE THIS REPORT
If you have Internet access, you may be able to complete this report online at www.ssa.gov/disability/appeal. If you complete this report on paper:
• Print or write clearly.
• Include a ZIP or postal code with each address.
• Provide complete phone numbers, including area code. If a phone number is outside the United States, also provide International Direct Dialing (IDD) code and country code.
• If you cannot remember the names and addresses of your health care providers, you may be able to get that information from the telephone book, Internet, medical bills, prescriptions, or prescription medicine containers.
• ANSWER EVERY QUESTION, unless this report indicates otherwise. You can write "don't know," or "none," or "does not apply" if you need to.
• If you need more space to answer any question, please use the REMARKS section on the last page, SECTION 10. Include the number of the question you are answering.
YOUR MEDICAL RECORDS
If you have any medical records that you have not given to us, send or bring them to our office with this completed report. Please tell us if you want us to return them to you. If you are having an interview in our office, bring your medical records, your prescription medicine containers (if available), and this completed report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will request your records. The information that you give us on this report tells us where to request your medical and other records.
HOW TO SUBMIT THIS REPORT
Send or bring this completed report to your local Social Security office. If you have Internet access, you can locate your nearest Social Security office by zip code at www.socialsecurity.gov/locator. Our offices are also listed under U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
Privacy Act Statement Disability Report - Appeal Collection and Use of Personal Information
Sections 205 (42 U.S.C. 405 (a) and (b)), 223 (42 U.S.C. 423 (d)), and 1631 (42 U.S.C. 1383 (e)(1)) of the Social Security Act, as amended, authorize us to collect this information. We will use the information you provide to update your disability report information.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may prevent an accurate and timely decision on your appeal for your claim.
We rarely use the information you provide on this form for any purpose other than to update your disability information. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity of Social Security programs (e.g., to the U.S. Census Bureau and to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act Systems of Records Notices entitled, Claims Folder System (60-0089) and Electronic Disability (60-0320). Additional information about these and other system of records notices and our programs are available online at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.
Paperwork Reduction Act
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 45 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to:SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401.
Send ONLY comments relating to our time estimate to this address, not the completed form.
AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT
FOR YOUR RECORDS.