Claimant's Medications - Form HA-4632

When you have requested or are requesting a hearing before an Administrative law Judge (ALJ), use this form to tell us about the medications you take. To ensure that we have current medical information, you should also complete an HA-4631, Claimant's Recent Medical Treatment. If you have worked since you filed your application for disability benefits, complete an HA-4633, Claimant's Work Background.

After you download the Adobe Acrobat Reader, come back to this page and download the PDF version of the HA-4632:

Claimant's Medications, HA-4632

CLAIMANT 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 information about the medicine you take to us.

B. In this section, tell us about your prescription and non-prescription medicine you take.

For your prescription medicines:

• enter (please print) the name of each prescription medicine you take and the dosage (amount you take at one time);
• when a doctor first prescribed the medicine;
• how much of the medicine you take each day;
• what medical problem you take the medicine for; and
• the name of the doctor who prescribed the medicine.

In the rest of the section, tell us about any non-prescription medicine you take. Include how often you take the medicine and the medical problem that you take it for.

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.