Form SSA-3826 Medical Report (General)

Form Approved.
OMB No. 0960-0052

SOCIAL SECURITY ADMINISTRATION

MEDICAL REPORT (General)
See Revised Privacy Act
Statement
PRIVACY ACT: The Social Security Administration is authorized to collect the information on this form under sections 205(a),
223(d)(5)(A), 1614(a)(3)(H)(i) and 1631(d)(1) of the Social Security Act. The information on this form is needed by Social Security to
complete processing of the named patient's claim. While giving us the information on this form is voluntary, failure to provide the
requested information may prevent an accurate or timely decision on the named patient's claim. Although the information you furnish on
this form is almost never used for any purpose other than making a determination about disability, such information may be disclosed by
the Social Security Administration to another person or governmental agency only with respect to Social Security programs and to comply
with federal laws requiring the exchange of information between Social Security and another agency.
Computer Matching Statement: We may also use the information you give us when we match records by computer. Matching programs compare our
records with those of other Federal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies
for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why
information about you may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security
office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by Section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take about 30 minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO THE OFFICE THAT REQUESTED IT. If you do not know the address, you may call Social Security at
1-800-772-1213(TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed form. See Paperwork Reduction

Identifying
Information
(To be completed by
Requesting
Office)

Act
Statement
SOCIAL SECURITY NO.

PATIENT'S NAME

DATE OF BIRTH

WAGE EARNER'S NAME (if different from patient)

NAME AND ADDRESS OF REQUESTING OFFICE

-

-

NAME OF MEDICAL SOURCE

NOTICE TO MEDICAL SOURCE:

PLEASE INCLUDE SUFFICIENT DETAILS OF HISTORY, PHYSICAL AND DIAGNOSTIC FINDINGS, CLINICAL COURSE,
THERAPY AND RESPONSE TO ENABLE A REVIEWING MEDICAL CONSULTANT TO MAKE AN INDEPENDENT
DETERMINATION AS TO THE SEVERITY AND DURATION OF THE IMPAIRMENT.

I.

HISTORY:

DATE YOU FIRST EXAMINED PATIENT

DATE OF MOST RECENT EXAMINATION

FREQUENCY OF VISITS

1

Form SSA-3826-F4 (2-2008) ef (2-2008) Prior edition may be used until stock is exhausted

II. MEDICAL FINDINGS: Please show all pertinent findings (with dates).
HEIGHT

WEIGHT

Form SSA-3826-F4 (2-2008) ef (2-2008)

2

Ill. LABORATORY AND SPECIAL STUDIES: Give results of all pertinent studies with dates. (In the case of ECGs and
PFSs please attach a copy of the tracing.)

Form SSA-3826-F4 (2-2008) ef (2-2008)

3

IV. DIAGNOSES:
1.
2.
3.

V. TREATMENT and RESPONSE

VI. ABILITY TO MANAGE FUNDS COMPLETE IF MENTAL DIAGNOSIS
In our opinion, is the patient able to manage his/her own funds?

REPORTING MEDICAL SOURCE'S NAME AND ADDRESS (Type or Print)

Form SSA-3826-F4 (2-2008) ef (2-2008)

NO (Explain)

YES

SIGNATURE

TITLE

TELEPHONE NUMBER (Include area code)

DATE

4

SSA will insert the following revised Privacy Act Statement into the form
at its next scheduled reprinting:
Privacy Act Statement
Medical Report (General)
Section 205(a) 223(d)(5)(A), 1604(a)(3)(H) and 1631(d)(1) of the Social Security Act, as
amended and (42 U.S.C. §§ 402-405, 423, 426, 428, 1382, 1383, 1395i-2, 1395o, and
1395s) authorize us to collect this information. The purpose of collecting this
information is to enable the Social Security Administration (SSA) to complete the
processing of the patient’s claim. Your response is voluntary. However, failure to
provide this requested information may prevent an accurate and timely decision on any
claim filed or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for the
reasons stated above. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routines uses, which include but are not
limited to the following:
1) To enable a third party or an agency to assist Social Security in establishing
rights to Medicare benefits or coverage;
2) To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans Affairs);
3) To make determination for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and,
4) To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Medicare programs.
We may also use the information you provide in Computer Matching programs.
Matching programs compare our records kept by other Federal, State, or local
government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used
or given out are available in Systems of Record Notice 60-0089 (Claims Folders Systems,
SSA, Office of the General Counsel, Office of Public Disclosure). This notice, additional
information about this form, and any other information regarding our systems and
programs are available on-line at www.socialsecurity.gov or at your local Social Security
office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 30
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.