99 lines
No EOL
14 KiB
HTML
99 lines
No EOL
14 KiB
HTML
<!DOCTYPE html>
|
|
<html class="no-js" lang="en">
|
|
|
|
<head>
|
|
<!-- REQUIRED META INFORMATION -->
|
|
<meta charset="UTF-8" />
|
|
<meta http-equiv="X-UA-Compatible" content="IE=edge" />
|
|
<meta name="viewport" content="width=device-width, initial-scale=1" />
|
|
<meta name="msapplication-tap-highlight" content="no" />
|
|
<!-- PAGE TITLE -->
|
|
<title>Form HA-4632 | Claimant's Medications | Social Security Administration</title>
|
|
<!-- PAGE META INFORMATION -->
|
|
<meta name="DCTERMS:coder" content="^DCBFM Website" />
|
|
<meta name="DCTERMS:coderOffice" content="DCBFM:SSS:WEB" />
|
|
<meta name="DCTERMS:contentOffice" content="OCA:LJ:FPSMB" />
|
|
<meta name="DCTERMS:contentOwner" content="jcarle" />
|
|
<meta name="DCTERMS:dateCertified" content="2019-01-24" />
|
|
<meta name="description" content="Form HA-4632 | Claimant's Medications" />
|
|
<!-- STYLES -->
|
|
<link rel="stylesheet" href="/framework/css/ssa.firefly.css" />
|
|
<!-- SCRIPTS -->
|
|
<script src="/framework/js/ssa.firefly.head.js"></script>
|
|
|
|
<script>(window.BOOMR_mq=window.BOOMR_mq||[]).push(["addVar",{"rua.upush":"false","rua.cpush":"false","rua.upre":"false","rua.cpre":"false","rua.uprl":"false","rua.cprl":"false","rua.cprf":"false","rua.trans":"","rua.cook":"false","rua.ims":"false","rua.ufprl":"false","rua.cfprl":"false","rua.isuxp":"false","rua.texp":"norulematch","rua.ceh":"false","rua.ueh":"false","rua.ieh.st":"0"}]);</script>
|
|
<script>!function(e){var n="https://s.go-mpulse.net/boomerang/";if("False"=="True")e.BOOMR_config=e.BOOMR_config||{},e.BOOMR_config.PageParams=e.BOOMR_config.PageParams||{},e.BOOMR_config.PageParams.pci=!0,n="https://s2.go-mpulse.net/boomerang/";if(window.BOOMR_API_key="LERZW-HECFS-R8H4E-23UQ7-ERMQB",function(){function e(){if(!o){var e=document.createElement("script");e.id="boomr-scr-as",e.src=window.BOOMR.url,e.async=!0,i.parentNode.appendChild(e),o=!0}}function t(e){o=!0;var n,t,a,r,d=document,O=window;if(window.BOOMR.snippetMethod=e?"if":"i",t=function(e,n){var t=d.createElement("script");t.id=n||"boomr-if-as",t.src=window.BOOMR.url,BOOMR_lstart=(new Date).getTime(),e=e||d.body,e.appendChild(t)},!window.addEventListener&&window.attachEvent&&navigator.userAgent.match(/MSIE [67]\./))return window.BOOMR.snippetMethod="s",void t(i.parentNode,"boomr-async");a=document.createElement("IFRAME"),a.src="about:blank",a.title="",a.role="presentation",a.loading="eager",r=(a.frameElement||a).style,r.width=0,r.height=0,r.border=0,r.display="none",i.parentNode.appendChild(a);try{O=a.contentWindow,d=O.document.open()}catch(_){n=document.domain,a.src="javascript:var d=document.open();d.domain='"+n+"';void(0);",O=a.contentWindow,d=O.document.open()}if(n)d._boomrl=function(){this.domain=n,t()},d.write("<bo"+"dy onload='document._boomrl();'>");else if(O._boomrl=function(){t()},O.addEventListener)O.addEventListener("load",O._boomrl,!1);else if(O.attachEvent)O.attachEvent("onload",O._boomrl);d.close()}function a(e){window.BOOMR_onload=e&&e.timeStamp||(new Date).getTime()}if(!window.BOOMR||!window.BOOMR.version&&!window.BOOMR.snippetExecuted){window.BOOMR=window.BOOMR||{},window.BOOMR.snippetStart=(new Date).getTime(),window.BOOMR.snippetExecuted=!0,window.BOOMR.snippetVersion=12,window.BOOMR.url=n+"LERZW-HECFS-R8H4E-23UQ7-ERMQB";var i=document.currentScript||document.getElementsByTagName("script")[0],o=!1,r=document.createElement("link");if(r.relList&&"function"==typeof r.relList.supports&&r.relList.supports("preload")&&"as"in r)window.BOOMR.snippetMethod="p",r.href=window.BOOMR.url,r.rel="preload",r.as="script",r.addEventListener("load",e),r.addEventListener("error",function(){t(!0)}),setTimeout(function(){if(!o)t(!0)},3e3),BOOMR_lstart=(new Date).getTime(),i.parentNode.appendChild(r);else t(!1);if(window.addEventListener)window.addEventListener("load",a,!1);else if(window.attachEvent)window.attachEvent("onload",a)}}(),"".length>0)if(e&&"performance"in e&&e.performance&&"function"==typeof e.performance.setResourceTimingBufferSize)e.performance.setResourceTimingBufferSize();!function(){if(BOOMR=e.BOOMR||{},BOOMR.plugins=BOOMR.plugins||{},!BOOMR.plugins.AK){var n=""=="true"?1:0,t="",a="vht6pfix22vgcz6v4n2a-f-afec32f92-clientnsv4-s.akamaihd.net",i="false"=="true"?2:1,o={"ak.v":"39","ak.cp":"1204614","ak.ai":parseInt("728289",10),"ak.ol":"0","ak.cr":3,"ak.ipv":4,"ak.proto":"http/1.1","ak.rid":"dedbadf","ak.r":35636,"ak.a2":n,"ak.m":"dsca","ak.n":"essl","ak.bpcip":"169.231.231.0","ak.cport":36720,"ak.gh":"23.214.170.101","ak.quicv":"","ak.tlsv":"tls1.3","ak.0rtt":"","ak.0rtt.ed":"","ak.csrc":"-","ak.acc":"bbr","ak.t":"1742070644","ak.ak":"hOBiQwZUYzCg5VSAfCLimQ==5U0eWCsl3rmwk2rADnt8rfMSqstWQNrMXp+zEu+JQXSCewtUK+XXI87H+y+2B5Nr3lJizvZiddyHohdtzrlhB6b3fJ+0o6vvQKVO37JXZbBT2mtNTt1IBkNw2Xmwm/RFUFu9bG5BzIu3meIFJ5hkXsiSXLoohyVk7J0CAuxO+ko9gpAZwMAzULwo26BWnd0rJK7BwCUQeh3bR5sqvygcVVQjtkiUExPX9gWjex4CuSCvLB7fPTxcbLRQwc0jI5Hzg359HXoYqoccm6sDZs33JnjZuCVUaUPj62POtzdbROLsi+KOD6WSrPFIRdcXQLBnf+XWiXME+TX0NK1nKisAmAXaC61wUe2fTo18D9N/A4t0Jc848gNeTdjmIbzmgnWjAfcW3H7yN1huOKoZR8aWnIugDEx6R3dXiM0mQvK6Nbo=","ak.pv":"98","ak.dpoabenc":"","ak.tf":i};if(""!==t)o["ak.ruds"]=t;var r={i:!1,av:function(n){var t="http.initiator";if(n&&(!n[t]||"spa_hard"===n[t]))o["ak.feo"]=void 0!==e.aFeoApplied?1:0,BOOMR.addVar(o)},rv:function(){var e=["ak.bpcip","ak.cport","ak.cr","ak.csrc","ak.gh","ak.ipv","ak.m","ak.n","ak.ol","ak.proto","ak.quicv","ak.tlsv","ak.0rtt","ak.0rtt.ed","ak.r","ak.acc","ak.t","ak.tf"];BOOMR.removeVar(e)}};BOOMR.plugins.AK={akVars:o,akDNSPreFetchDomain:a,init:function(){if(!r.i){var e=BOOMR.subscribe;e("before_beacon",r.av,null,null),e("onbeacon",r.rv,null,null),r.i=!0}return this},is_complete:function(){return!0}}}}()}(window);</script></head>
|
|
|
|
<body>
|
|
<!-- BANNER -->
|
|
<aside class="accessibility" id="accessibility"><a href="#content" id="skip-navigation">Skip to main content</a></aside>
|
|
<!-- WCMS SITE ALERT (EMERGENCY) -->
|
|
<div class="print-dn wcms" aria-label="Site Alert" style="background-color: #FFE396;">
|
|
<div class="fx mx-auto px3 py2" style="max-width: 75rem;">
|
|
<svg class="fx-none mr2 svg3" focusable="false" viewbox="0 0 20 20" aria-hidden="true">
|
|
<path fill="#FFFFFF" fill-rule="evenodd" stroke-width="0" d="M10.8,15h-1.7v-1.7h1.7v1.7ZM10.8,11.7h-1.7v-4.9h1.7v4.9Z" vector-effect="non-scaling-stroke"></path>
|
|
<path fill="#1C1D1F" fill-rule="evenodd" stroke-width="0" d="M.8,17.5h18.3L10,1.7.8,17.5ZM10.8,15h-1.7v-1.7h1.7v1.7ZM10.8,11.7h-1.7v-4.9h1.7v4.9h0Z" vector-effect="non-scaling-stroke"></path>
|
|
</svg>
|
|
<a class="cc" href="https://www.ssa.gov/manage-benefits/make-an-appointment"><u>If you need to visit an office, schedule an appointment first. Find out how.</u></a>
|
|
</div>
|
|
</div>
|
|
<!-- WCMS SITE ALERT (INFORMATION) -->
|
|
<div class="print-dn wcms" aria-label="Site Alert" style="background-color: #E7F6F8;">
|
|
<div class="fx mx-auto px3 py2" style="max-width: 75rem;">
|
|
<svg class="fx-none mr2 svg3" focusable="false" viewbox="0 0 20 20" aria-hidden="true">
|
|
<path fill="#1C1D1F" fill-rule="evenodd" stroke-width="0" d="M10,1.7C5.4,1.7,1.7,5.4,1.7,10s3.7,8.3,8.3,8.3,8.3-3.7,8.3-8.3S14.6,1.7,10,1.7ZM9.2,7.5v-1.7h1.7v1.7h-1.7ZM9.2,9.2v5h1.7v-5h-1.7Z" vector-effect="non-scaling-stroke"></path>
|
|
<path fill="#FFFFFF" fill-rule="evenodd" stroke-width="0" d="M10.8,7.5h-1.7v-1.7h1.7v1.7Z" vector-effect="non-scaling-stroke"></path>
|
|
<path fill="#FFFFFF" fill-rule="evenodd" stroke-width="0" d="M10.8,14.2h-1.7v-5h1.7v5Z" vector-effect="non-scaling-stroke"></path>
|
|
</svg>
|
|
<a class="cc" href="https://www.ssa.gov/benefits/retirement/social-security-fairness-act.html"><u>Information about the Social Security Fairness Act (WEP/GPO)</u></a>
|
|
</div>
|
|
</div>
|
|
<ssa-header class="print-dn"><noscript><header class="bg-logo white" id="banner" role="banner" style="background-color: #0b4778;"><div class="fx fx-jc-sb px2 py0 wrapper"><div class="fs2 fw4 ma0 l-fs3"><a class="fx fx-ai-c hover-yellow py3 white m-py2" href="/"><img alt="" class="svg3 m-svg5" src="/framework/images/logo.svg" height="64" width="64"> <span class="pl1 m-pl2">Social Security</span></a></div><nav class="fs1 fx print-dn"><a class="fx fx-ai-c hover-yellow px2 white" href="https://search.ssa.gov/search?affiliate=ssa" id="ssa-search" title="Search" target="_blank"><svg class="svg1" focusable="false" viewbox="0 0 24 24"><path d="M14.182.0q-1.994.0-3.814.78t-3.132 2.092-2.092 3.132-.78 3.814q0 1.713.558 3.281t1.59 2.847l-6.196 6.187q-.315.315-.315.776.0.469.311.78t.78.311q.46.0.776-.315l6.187-6.196q1.278 1.031 2.847 1.59t3.281.558q1.994.0 3.814-.78t3.132-2.092 2.092-3.132.78-3.814-.78-3.814-2.092-3.132-3.132-2.092-3.814-.78zm0 2.182q1.551.0 2.966.605t2.438 1.628 1.628 2.438.605 2.966-.605 2.966-1.628 2.438-2.438 1.628-2.966.605-2.966-.605-2.438-1.628-1.628-2.438-.605-2.966.605-2.966 1.628-2.438 2.438-1.628 2.966-.605z" vector-effect="non-scaling-stroke"></path></svg> <span class="dn m-dib m-pl1">Search</span> </a><a class="fx fx-ai-c hover-yellow px2 white" href="/menu" id="ssa-menu" title="Menu"><svg class="svg1" focusable="false" viewbox="0 0 24 24"><path d="M3 5h18q.414.0.707.293T22 6t-.293.707T21 7H3q-.414.0-.707-.293T2 6t.293-.707T3 5zm0 12h18q.414.0.707.293T22 18t-.293.707T21 19H3q-.414.0-.707-.293T2 18t.293-.707T3 17zm0-6h18q.414.0.707.293T22 12t-.293.707T21 13H3q-.414.0-.707-.293T2 12t.293-.707T3 11z" vector-effect="non-scaling-stroke"></path></svg> <span class="dn m-dib m-pl1">Menu</span> </a><a class="fx fx-ai-c hover-yellow px2 white" hreflang="es" href="/es" id="ssa-languages" title="Español"><svg class="svg1" focusable="false" viewbox="0 0 14 16"><path fill-rule="evenodd" d="M7 1C3.14 1 0 4.14.0 8s3.14 7 7 7c.48.0.94-.05 1.38-.14-.17-.08-.2-.73-.02-1.09.19-.41.81-1.45.2-1.8-.61-.35-.44-.5-.81-.91-.37-.41-.22-.47-.25-.58-.08-.34.36-.89.39-.94.02-.06.02-.27.0-.33.0-.08-.27-.22-.34-.23-.06.0-.11.11-.2.13-.09.02-.5-.25-.59-.33-.09-.08-.14-.23-.27-.34-.13-.13-.14-.03-.33-.11s-.8-.31-1.28-.48c-.48-.19-.52-.47-.52-.66-.02-.2-.3-.47-.42-.67-.14-.2-.16-.47-.2-.41-.04.06.25.78.2.81-.05.02-.16-.2-.3-.38-.14-.19.14-.09-.3-.95s.14-1.3.17-1.75c.03-.45.38.17.19-.13-.19-.3.0-.89-.14-1.11-.13-.22-.88.25-.88.25.02-.22.69-.58 1.16-.92.47-.34.78-.06 1.16.05.39.13.41.09.28-.05-.13-.13.06-.17.36-.13.28.05.38.41.83.36.47-.03.05.09.11.22s-.06.11-.38.3c-.3.2.02.22.55.61s.38-.25.31-.55c-.07-.3.39-.06.39-.06.33.22.27.02.5.08.23.06.91.64.91.64-.83.44-.31.48-.17.59.14.11-.28.3-.28.3-.17-.17-.19.02-.3.08-.11.06-.02.22-.02.22-.56.09-.44.69-.42.83.0.14-.38.36-.47.58-.09.2.25.64.06.66-.19.03-.34-.66-1.31-.41-.3.08-.94.41-.59 1.08.36.69.92-.19 1.11-.09.19.1-.06.53-.02.55.04.02.53.02.56.61.03.59.77.53.92.55.17.0.7-.44.77-.45.06-.03.38-.28 1.03.09.66.36.98.31 1.2.47.22.16.08.47.28.58.2.11 1.06-.03 1.28.31.22.34-.88 2.09-1.22 2.28-.34.19-.48.64-.84.92s-.81.64-1.27.91c-.41.23-.47.66-.66.8 3.14-.7 5.48-3.5 5.48-6.84.0-3.86-3.14-7-7-7L7 1zm1.64 6.56c-.09.03-.28.22-.78-.08-.48-.3-.81-.23-.86-.28.0.0-.05-.11.17-.14.44-.05.98.41 1.11.41.13.0.19-.13.41-.05.22.08.05.13-.05.14zM6.34 1.7c-.05-.03.03-.08.09-.14.03-.03.02-.11.05-.14.11-.11.61-.25.52.03-.11.27-.58.3-.66.25zm1.23.89c-.19-.02-.58-.05-.52-.14.3-.28-.09-.38-.34-.38-.25-.02-.34-.16-.22-.19.12-.03.61.02.7.08.08.06.52.25.55.38.02.13.0.25-.17.25zm1.47-.05c-.14.09-.83-.41-.95-.52-.56-.48-.89-.31-1-.41-.11-.1-.08-.19.11-.34.19-.15.69.06 1 .09.3.03.66.27.66.55.02.25.33.5.19.63h-.01z" vector-effect="non-scaling-stroke"></path></svg> <span class="dn m-dib m-pl1">Español</span> </a><a class="fx fx-ai-c hover-yellow px2 white" href="https://secure.ssa.gov/RIL/SiView.action" id="ssa-signin" title="Sign in" target="_blank"><svg class="svg1" focusable="false" viewbox="0 0 24 24"><path d="M12 17.016q-.797.0-1.406-.61t-.61-1.405.61-1.405 1.406-.61 1.406.61.61 1.406-.61 1.407-1.406.61zm6 3V9.986H6v10.03h12zm-6-17.11q-1.266.0-2.18.914T8.906 6H9v2.016h6.094V6q0-1.266-.914-2.18T12 2.906zm6 5.11q.797.0 1.406.586t.61 1.383v10.03q0 .798-.61 1.384T18 21.984H6q-.797.0-1.406-.586t-.61-1.384V9.986q0-.798.61-1.384T6 8.016h.984V6q0-2.063 1.477-3.54T12 .985t3.54 1.477T17.015 6v2.016H18z" vector-effect="non-scaling-stroke"></path></svg> <span class="dn m-dib m-pl1">Sign in</span></a></nav></div></header></noscript></ssa-header><script src="https://www.ssa.gov/legacy/components/dist/ssa-header.js"></script>
|
|
<!-- MAIN CONTENT -->
|
|
<main class="content" id="content" role="main">
|
|
<!-- TITLE BAR -->
|
|
<section class="bg-ivory-200">
|
|
<!-- WRAPPER -->
|
|
<div class="wrapper py2">
|
|
<h2 class="fw4 ma0">Form HA-4632 | Claimant's Medications</h2>
|
|
</div>
|
|
</section>
|
|
|
|
<!-- WRAPPER -->
|
|
<section class="wrapper">
|
|
|
|
<!-- GRID -->
|
|
<div class="m-grid">
|
|
|
|
<!-- CELL -->
|
|
<article class="m-cell m-w-70">
|
|
<section>
|
|
<p>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.</p>
|
|
<p><a href="ha-4632.pdf">HA-4632, Claimant's Medications</a></p>
|
|
<p>To ensure that we have current medical information, you should also complete an <a href="ha-4631.html">HA-4631, Claimant's Recent Medical Treatment</a>. If you have worked since you filed your application for disability benefits, complete an <a href="ha-4633.html">HA-4633, Claimant's Work Background</a>.</p>
|
|
<div class="alert-blue">
|
|
<p><strong>Where to send this form</strong></p>
|
|
<p>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.</p>
|
|
</div>
|
|
</section>
|
|
</article>
|
|
|
|
<!-- CELL -->
|
|
<aside class="m-cell m-w-30">
|
|
<h3 class="by">Related Information</h3>
|
|
<ul>
|
|
<li><a href="/forms/">More forms</a></li>
|
|
</ul>
|
|
</aside>
|
|
|
|
</div>
|
|
|
|
</section>
|
|
</main>
|
|
<!-- FOOTER -->
|
|
<ssa-footer class="print-dn"><noscript><footer class="fs1 print-dn" id="footer" role="contentinfo"><div class="wrapper"><a class="db" href="/menu#footer">Footer menu</a></div></footer></noscript></ssa-footer><script src="https://www.ssa.gov/legacy/components/dist/ssa-footer.js"></script>
|
|
<!-- SCRIPTS -->
|
|
<script src="/framework/js/ssa.firefly.body.js"></script>
|
|
</body>
|
|
|
|
</html> |