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... |
