Claimant's Recent Medical Treatment - Form HA-4631

Introduction

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.

How to Obtain the Form

Below you will find Form in Portable Document Format (PDF). To print the PDF version, you will need the Adobe Acrobat reader software. If you do not already have this special software, see our page on downloading and printing PDF documents.

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

Where To Send The Form

Print the PDF HA-4631 form on 8 1/2 x 11 inch paper, complete the form, and mail it to the hearing office where your claim is located. The address and telephone number of the hearing office are on the letter acknowledging receipt of the request for hearing that we sent.


	Privacy Policy \| Website Policies & Other Important Information \| Site Map Last reviewed or modified Wednesday Apr 01, 2009	Need Larger Text?