Claimant's Recent Medical Treatment - Form HA-4631

When 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.

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

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.

1. For any doctor you have seen outside of a hospital, list:
   • the doctor's full name, address, and telephone number; and
   • the dates you saw the doctor.
2. For each doctor, tell us:
   • why you saw the doctor;
   • what he or she told you about your condition; and
   • what treatment or medication he or she prescribed.
3. If you have been hospitalized, please list:
   • the name and address of the hospital;
   • the dates you were hospitalized (admitted and discharged or seen in an emergency room);
   • the reason you were hospitalized; and
   • the treatment you received.

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.