SSA-199
Vocational Rehabilitation Provider Claim
Download and Print
the SSA-199
Request may not be processed if the form is incomplete or illegible.
To:
Social Security Administration -
Office of Employment Support Programs
VRA Operations Team
P.O. Box 17714
Baltimore, Maryland 21235-7714
From:
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...
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