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HA-4632

Claimant's Work Background

Download and Print the HA-4632

Request may not be processed if the form is incomplete or illegible.

CLAIMANT'S MEDICATIONS

A.

To be completed by Hearing Office
(Claimant and Social Security Number)
(Wage Earner and Social Security Number) (Leave blank if same as claimant)
The last time we brought your case up-to-date was:

B.

To be completed by the claimant - PLEASE PRINT

PLEASE LIST BELOW THE PRESCRIPTION MEDICATION WHICH YOU ARE PRESENTLY TAKING.

IF THE NAME OF THE MEDICATION IS NOT SHOWN ON THE PRESCRIPTION CONTAINER, YOU MAY VERIFY THE NAME WITH YOUR PHARMACIST.

NAME OF MEDICATION & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

And much more...

 
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