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How to fill out SSA form HA-4632

Form HA-4632 is the form used by the Social Security Administration (SSA) to list all of the medications you’re taking while filing for Social Security disability benefits. It is important to fill this form out thoroughly and not to leave anything out. When you’re building a case for Social Security disability benefits, the more evidence you can show to demonstrate that you are both seriously disabled and doing what you can to cope with your disabilities, the better.

You don’t need to fill out Section A of Form HA-4632. This section includes information about the claimant, wage earner (if a different person than the claimant) and when the claim was last updated. The Hearing Office should have this filled out for you before they give you the form. Check to make sure that everything in Section A is filled out and bring it to the Hearing Office’s attention if it isn’t.

*Note: Wage earner information may be left blank if the claimant and wage earner is the same person.

In Section B, you need to completely fill out each column for every prescription medication you are currently taking. You can find much of this information on your prescription bottles themselves. If you can’t, call your pharmacist or doctor to obtain the needed information. Take the time to make calls if necessary rather than leaving sections blank. It may seem like a small thing to leave off something like the date a medication was first prescribed to you, but Social Security Disability claims have been denied for just such reasons.

You should always be truthful and complete when filling out this form. If you have any questions regarding whether or not information should be included, consult a Social Security disability lawyer.

  • In the first column, list each medication you take and the dosage. You can generally find the dosage printed on the prescription bottle. If you can’t, call your pharmacy or doctor’s office. The form only has space for four prescription medications. If you are taking more than four prescriptions, fill out the rest on a separate sheet of paper. Make a note at the bottom of the section that there is an addendum to this form.
  • In the next column, fill out the date the medication was first prescribed to you. I you’re not sure, your doctor’s office or pharmacy will have this information.
  • In the third column, indicate how much you actually take per day.
  • In the fourth column, explain why the medication is prescribed to you. If you don’t know, ask your doctor.
  • In the final column, list the doctor who prescribed the medication to you.

In the nonprescription section, list all medications you take, how often you take them, and why you take them. Don’t hold back on this section. If you regularly take over the counter pain meds, include that information. Social Security disability claims are often decided based on the overall effect of all medical problems and medications taken, so include everything.