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Form SSA-454-BK 04-2014 ef 04-2014 Destroy Prior Editions Privacy Act Statement Collection and Use of Personal Information Sections 205 a 223 d and 1631 e 1 of the Social Security Act as amended authorize us to collect this information. We will use the information you provide to make a decision on the named claimant s claim. Furnishing us this information is voluntary. CONTINUING DISABILITY REVIEW REPORT SSA-454-BK PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT The office that reviews your medical condition will use the information in this report. The information will help that office decide whether you are still disabled* Please complete as much of the report as you can* IF YOU NEED HELP You can get help from other people such as a friend or family member. Please do not ask your health care provider to complete this report. If you cannot complete the report a Social Security Representative will assist you. If you have an appointment please have the completed report ready when we contact you. Note If you are assisting someone else with this report please answer the questions as if that person were completing the report. HOW TO COMPLETE THIS REPORT Print or write clearly. Include a ZIP or postal code with each address. Provide complete phone numbers including area code. If a phone number is outside the United States provide International Direct Dialing IDD code and country code. If you cannot remember the names and addresses of your health care providers you may be able to get that information from the telephone book Internet medical bills prescriptions or prescription medicine containers. ANSWER EVERY QUESTION unless the report indicates otherwise. If you do not know an answer or the answer is none or does not apply please write don t know or none or does not apply. Be sure to explain an answer if the question asks for an explanation or if you want to give additional information* If you need more space to answer any question please use Section 11 - Remarks on the last page to finish your answer. Write the number of the question you are answering. YOUR MEDICAL RECORDS If you have any of your medical records covering the last 12 months send or bring them to our office with this completed report. Please tell us if you want to keep your records so we can return them to you. If you have a scheduled appointment for an interview bring your medical records your YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT YOU DO NOT ALREADY HAVE* With your permission we will request your records. The information that you give us on this report tells us where to request your medical and other records. However failing to provide us with all or part of the information could prevent an accurate or timely decision on the named claimant s claim* We rarely use the information you supply for any purpose other than to make a decision on the named claimant s claim* However we may use the information for the administration of our programs including sharing information 1.

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