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Vocational Rehabilitation Provider Claim

Download and Print the SSA-199

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

Social Security Administration - Office of Employment Support Programs

VRA Operations Team

P.O. Box 17714

Baltimore, Maryland 21235-7714


VR Provider Code

Check One:  -  Claim Based On:  -  Continuous Period of SGA - Medical Recovery during VR

If claim is based upon other than a continuous period of SGA, it is not necessary to complete items 6, 8, 9, or 13 below.

Check One: Initial Claim   -  Reconsideration -  Resubmittal -  Supplemental

1. Client (First Name, MI, Last Name)

And much more...