SSA-789-U4 2015 free printable template

1. SIGNATURE OF WITNESS ADDRESS NUMBER AND STREET CITY STATE ZIP CODE ADDRESS NUMBER AND STREET CITY STATE ZIP CODE Form SSA-789-U4 09-2015 EF 09-2015 Use Prior edition until exhausted 12-2009 EF 12-2009 CLAIMS FILE PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE Sections 205 a b 1631 c 1 A and B of the Social Security Act as amended allow us to collect this information. We will use the information you provide to determine your eligibility for disability benefits. SOCIAL SECURITY...

How to fill out SSA-789-U4

How to fill out SSA-789-U4

1. Obtain the SSA-789-U4 form from the Social Security Administration's website or local office.
2. Read the instructions on the form carefully before starting.
3. Fill out personal information such as your name, Social Security number, and contact details in the designated sections.
4. Provide information about your disability, including the nature of the impairment and how it affects your daily life.
5. If applicable, include details about medical treatments or diagnoses relevant to your disability.
6. Answer all questions truthfully and to the best of your knowledge.
7. Review the completed form for any errors or omissions.
8. Sign and date the form before submitting it.

Who needs SSA-789-U4?

1. Individuals applying for Social Security Disability Insurance (SSDI) benefits.
2. Workers applying for Supplemental Security Income (SSI) due to a disability.
3. Anyone seeking to report a change in their disability status to the Social Security Administration.

Instructions and Help about SSA-789-U4

People Also Ask about

What is SSA 789 form from Social Security?

A. Overview of the SSA-789 The claimant, an appointed representative, a representative payee or other third party filing on the claimant's behalf can use the SSA-789 Request for Reconsideration to request reconsideration on an initial disability cessation determination.

What is a SSA 827 form?

SSA and its affiliated State disability determination services use Form SSA-827, "Authorization to Disclose Information to the Social Security Administration (SSA)" to obtain medical and other information needed to determine whether or not a claimant is disabled.

What is the SSA 795 form used for?

General information for recording statements on the SSA-795. Use an SSA-795 whenever a signed statement is required or desirable, except when we request some other form or questionnaire or we can readily adapt for the statement.

What is a SSA 795 form used for?

General information for recording statements on the SSA-795. Use an SSA-795 whenever a signed statement is required or desirable, except when we request some other form or questionnaire or we can readily adapt for the statement.

What is SSA 787 form?

The SSA-787, Medical Source Opinion of Patient's Capability to Manage Benefits, is the preferred vehicle for obtaining medical evidence of capability.

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What is SSA-789-U4?

SSA-789-U4 is a form used by the Social Security Administration (SSA) to collect information about a person's medical condition and how it impacts their ability to work.

Who is required to file SSA-789-U4?

Individuals who are applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits may be required to file SSA-789-U4 as part of their application process.

How to fill out SSA-789-U4?

To fill out SSA-789-U4, the applicant should provide personal information, detailed descriptions of their medical conditions, treatment history, and the impact of their disabilities on daily activities and work capabilities.

What is the purpose of SSA-789-U4?

The purpose of SSA-789-U4 is to gather necessary medical and functional information to help determine an individual's eligibility for disability benefits.

What information must be reported on SSA-789-U4?

The form requires reporting on personal identification details, medical conditions, treatment history, limitations on work capacity, and the effect of disabilities on daily living activities.