Form SSA-455-OCR-SM "Disability Update Report"

What Is Form SSA-455-OCR-SM?

Form SSA-455-OCR-SM, Disability Update Report, is a form mailed to a disabled beneficiary or their representative in order to update information about their condition and treatment they received in the past two years. The most recent version of this form was issued by the U.S. Social Security Administration (SSA) on October 1, 2013. Download a PDF version of the Form SSA-455-OCR-SM through the link below.

Alternate Names:

  • SSA Disability Update Report;
  • Continuing Disability Report.

The form has two versions, the longer and the shorter. The shorter form, Form SSA-455, Disability Update Report, does not require much information and is processed by a computer. Based on the information provided on this form, the SSA will decide whether or a medical review is required. If the SSA Disability Update Report is accepted, the SSA will send a notice in that regard. If the SSA requires more information and a full medical review, the beneficiary will receive Form SSA-455-OCR-SM often referred to as the "Long Form." This is a 10-page form, requiring more information about the beneficiary's medical condition, treatment, education and work activity, etc.

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How to Fill Out Form SSA-455-OCR-SM?

  1. Indicate whether you have been working for someone or been self-employed during the reporting period in Question 1A.
  2. If you answered the previous question positively, enter the date you began and stopped working and your gross monthly earnings in Question 1B. If you are working at present, enter the current month and year in the box titled "Month Ended." Describe the most recent working activity.
  3. Indicate whether you attended any school or training program during the reporting period in Question 2.
  4. Indicate whether you have discussed your ability to work with your doctor and whether they approved of your plans to work in Question 3.
  5. Enter an "X" in the corresponding box indicating whether your condition has improved, worsened, or has not changed since the last review (Question 4).
  6. Provide information about the treatment and whether you received it during the reporting period in Question 5A. This includes help provided by phone or other contacts.
  7. If you visited a doctor or clinic, enter the reasons, and dates of the most recent visits in Question 5B. Start with the most recent and then work backward in time.
  8. Indicate whether you were hospitalized or had surgery since the last update in Question 6A.
  9. If you answered positively to the previous question, provide reasons and dates of the received treatment in Question 6B.
  10. Use "Remarks" if the provided space is not enough or you need to include additional comments.

The frequency of mailing SSA Form 455-OCR-SM depends on the beneficiary's condition and if the improvement is expected. If it is not expected, the form will be mailed every 5 to 7 years. If there is a possibility of improvement, the beneficiary will receive an SSA Form 455 every three years. If improvement is expected, the SSA will mail a form-to-update every 6 to 18 months. The review frequency is different for each person. In addition, the form can be mailed after a certain event, such as turning 18 or receiving a work-related income.

Where to Send the Completed SSA Form 455-OCR-SM?

Mail the completed form to the return address on the envelope or, if there was none, send the form to the Social Security Administration, P.O. Box 4550, Wilkes-Barre, Pennsylvania 18767-4550. The completed form should be mailed within 30 days from the date it was received.

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Social Security Administration
Disability Update Report
Information and Completion Instructions
Why We Are
The Social Security Administration must regularly review the cases of
people getting disability benefits to make sure they are still disabled
Writing To
under our rules. It is time for us to review this case. Enclosed is a
You Now
Disability Update Report for you to answer to update us about
you (or the person for whom you are the representative payee), your
health and medical conditions, any recent work activity, or any recent
training.
What To
Please read the following information, and the instructions for
completing the report form, before you answer the questions.
Do First
When to
Please complete the report, sign it and send it to us in the enclosed
envelope within 30 days. If there is no return envelope with the report,
Respond
please send the signed report to us at:
Social Security Administration
P.O. Box 4550
Wilkes-Barre, PA 18767-4550
We consider the information you give us together with the information
What We Do
in your claim record to decide if we need to do a full medical review.
With Your
After we receive the completed report, we will notify you whether or not
Answers
we need to do a full medical review.
If You Need
It is important that information you give us is accurate. We have tried
to make report questions easy to understand and answer. But, if you
Help To
find that you do not understand a question or questions, please contact
Answer The
us, your authorized representative, a social service agency, your doctor
Report
or clinic, or some other person you trust.
If You Need
If you need to contact us, please call us toll-free at 1-800-772-1213
or TTY for the hearing impaired at 1-800-325-0778. We can answer
To Contact
most questions over the telephone. If you prefer to visit or call one of
Us
our offices, please use the 800 number to get the local office address
and telephone number. Please have the Disability Update Report with
you if you call or visit an office. It will help us answer your questions.
Also, if you plan to visit an office, you should call ahead to make an
appointment. This will help us serve you.
We May Need
Sometimes, we may need more information from you. If so, we will try
to call you. If you do not have a telephone, please give us a number
To Contact
where we can leave a message for you. Please print the telephone
You
number in the section provided on the back of the report form.
If you do not complete and return the report promptly, or tell us why
If We Don’t
you cannot respond, we may stop sending payments to you. If it is
Hear From You
necessary to stop your payments, we will send you another letter
telling you what we plan to do.
Continued on the Reverse
FORM SSA-455-OCR-SM (10-2013)
Social Security Administration
Disability Update Report
Information and Completion Instructions
Why We Are
The Social Security Administration must regularly review the cases of
people getting disability benefits to make sure they are still disabled
Writing To
under our rules. It is time for us to review this case. Enclosed is a
You Now
Disability Update Report for you to answer to update us about
you (or the person for whom you are the representative payee), your
health and medical conditions, any recent work activity, or any recent
training.
What To
Please read the following information, and the instructions for
completing the report form, before you answer the questions.
Do First
When to
Please complete the report, sign it and send it to us in the enclosed
envelope within 30 days. If there is no return envelope with the report,
Respond
please send the signed report to us at:
Social Security Administration
P.O. Box 4550
Wilkes-Barre, PA 18767-4550
We consider the information you give us together with the information
What We Do
in your claim record to decide if we need to do a full medical review.
With Your
After we receive the completed report, we will notify you whether or not
Answers
we need to do a full medical review.
If You Need
It is important that information you give us is accurate. We have tried
to make report questions easy to understand and answer. But, if you
Help To
find that you do not understand a question or questions, please contact
Answer The
us, your authorized representative, a social service agency, your doctor
Report
or clinic, or some other person you trust.
If You Need
If you need to contact us, please call us toll-free at 1-800-772-1213
or TTY for the hearing impaired at 1-800-325-0778. We can answer
To Contact
most questions over the telephone. If you prefer to visit or call one of
Us
our offices, please use the 800 number to get the local office address
and telephone number. Please have the Disability Update Report with
you if you call or visit an office. It will help us answer your questions.
Also, if you plan to visit an office, you should call ahead to make an
appointment. This will help us serve you.
We May Need
Sometimes, we may need more information from you. If so, we will try
to call you. If you do not have a telephone, please give us a number
To Contact
where we can leave a message for you. Please print the telephone
You
number in the section provided on the back of the report form.
If you do not complete and return the report promptly, or tell us why
If We Don’t
you cannot respond, we may stop sending payments to you. If it is
Hear From You
necessary to stop your payments, we will send you another letter
telling you what we plan to do.
Continued on the Reverse
FORM SSA-455-OCR-SM (10-2013)
If We Do A
If we decide to do a full medical review of your case, you can give us
any information which you believe shows that you are still disabled,
Full Medical
such as medical reports and letters from your doctors about your
Review
health. Then, we look at all your information in your case, including the
new information you give us, and decide whether you continue to be
disabled under our rules.
Appeals And
When we review your case, we may find that you are no longer disabled
under our rules, and your payments may stop. If your payments stop,
Continued
you can appeal our decision or you can ask us to continue to make
Benefits
payments while you appeal.
Do you want to work, but worry about losing your payments or
If You Want
Medicare before you can support yourself? We want to help you go to
To Work
work when you are ready. But, work and earnings may affect your
benefits. Your local Social Security office can tell you more about work
incentives, and how work and earnings can affect your benefits.
The Privacy
Collection and Use of Personal Information - Sections 205(a) and 1631(e)(1)(A) and (B)
of the Social Security Act, as amended, and Social Security regulations at 20 C.F.R. 404.1589
And
and 416.989 authorize us to collect this information. We will use the information you provide to
Paperwork
further document your claim and permit a determination about continuing disability.
Reduction
The information you furnish on this report is voluntary. However, failure to provide us with the
requested information could prevent us from making an accurate and timely decision on your
Acts
claim.
We rarely use this information you supply for any purpose other than for reviewing your claim
for Social Security benefits. 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 routine 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
Social Security benefits and/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 determinations 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 and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with 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.
A complete list of routine uses for this information are available in our Systems of Records Notices
entitled, Claims Folders Systems (60-0089) and the Master Beneficiary Record (60-0090). These
notices, additional information regarding this form, routine uses of information, and our programs
and systems are available online at www.socialsecurity.gov or at your local 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 (OMB)
control number. The OMB control number for this collection is 0960-0511. We estimate that it will
take 15 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.
FORM SSA-455-OCR-SM (10-2013)
2
GENERAL
The Disability Update Report is a scannable form which can be “read”
electronically. To help us process your report, please follow these
INSTRUCTIONS
instructions when you answer the questions on the report
- HOW TO
form:
COMPLETE
1. USE BLACK INK OR A #2 PENCIL.
2. KEEP YOUR NUMBERS, LETTERS, AND “X’S” INSIDE THE
“SCANNABLE”
BOXES.
FORMS
3. NUMBERS: Try to make your numbers look like these:
0 1 2 3 4 5 6 7 8 9
4. LETTERS: Print in CAPITALS. Try to make your letters look
like these:
A B C D E
F G H
I
K L
J
M
N O P Q R S T U V
X Y
W
Z
5. MONEY AMOUNTS: Show dollars only. Do not use dollar signs
($), and do not show cents. For example, show $1,540.30 like this:
Dollars Only, No Cents
1 5 4
0
0
,
6. DATES: Put a number in each box. For example, show September
9, 2003, like this:
Month
Year
0
9
3
0
7. THE REPORT PERIOD: The “report period” is the period of
time for which we need information. It is described at the top of
the report form to the right of your name, and again in questions 1
through 6. Usually, the report period is the last 24 months, but it
may be less. It is important that you keep the report period
in mind when answering the questions.
HOW TO FILL OUT THE REPORT FORM
QUESTION 1.a. -
If you have not worked during the report period, place an “X” in the
box below “NO”, and go on to question 2. If you have worked, mark the
Have You
box below “YES”, and answer question l.b.
Worked?
QUESTION 1.b. -
Describe your most recent work activity first. Print the months
and years you began and ended working in the boxes under “Work
When You
Began” and “Work Ended.” If you are working now, print the
Worked And
current month and year in the first set of boxes under “Work Ended.”
Your Monthly
Print your gross monthly earnings for the periods you worked in the
Earnings
boxes.
QUESTION 2 -
Place an “X” in the box below “YES” if you have attended school and/or
a training program during the report period; otherwise, mark the box
School Or Work
below “NO”. This could include high school equivalency programs,
Training
college courses, vocational evaluation or retraining programs, but
generally would not include group therapy or hobbies.
FORM SSA-455-OCR-SM (10-2013)
3
Continued on the Reverse
QUESTION 3 -
Tell us if you have discussed with your doctor whether you can return
to any kind of work, and if so, whether the doctor told you that you can
Can You Work?
return to work, even if the work permitted is less physically demanding
and/or less stressful than your usual work. Place an “X” in only 1 box.
QUESTION 4 -
We want to know how your overall health now compares to what it was
at the beginning of the report period. You may feel that your health has
How Is Your
gotten worse, has improved, or you may feel that your health is about the
Health?
same and has not gotten better or worse. Place an “X” in only 1 box.
QUESTION 5 -
A “doctor or clinic” can include treatment such as evaluations, checkups,
counseling, providing prescriptions or medicine by a doctor, visiting
Treatment By A
nurse, family health center, psychologist, licensed counseling service,
Doctor Or Clinic
physical therapist, a chiropractor or other licensed health provider.
Treatment may be provided in person or by telephone or other contact.
How To Answer
If you have not been treated by a doctor or clinic during the report
period, place an “X” in the box below “NO”, and go on to question 6. If
Question 5.a.
you have gone to a doctor or clinic during the report period, mark the
box below ‘’YES”, and answer question 5.b.
Question 5.b. -
Please start with the most recent visit and then work backwards
in time. Print as much information as will fit, but keep a space between
Reason For
each word. Try to use the most important or key word(s), such as
The Visit
ARTHRITIS or BAD BACK, or HYPERTENSION or HIGH BLOOD.
Your medical bills or doctor can provide a short, accurate description.
Print the month and year you were treated. Complete all 4 boxes. For
Date of Visit
example, print September 10, 2003, as 09 03.
NOTE: If needed, use the “REMARKS” section on side 2 of the form.
Place an “X” in the box below “NO” if you have not been hospitalized or
QUESTION 6.a -
not had surgery during the report period. If you have been hospitalized
Have You Been
or had surgery during the report period, then place an “X” in the box
Hospitalized Or
below ‘’YES” and answer question 6.b.
Had Surgery?
Question 6.b. -
Please report your most recent treatment first and then work
backwards in time. Try to provide the most important information.
Reason For
Keep a space between each word. Your medical bills or doctor can
Treatment
provide short, accurate words.
Date of
Print the month and year you were hospitalized or had surgery. Be
Treatment
sure to use all four spaces. If you were hospitalized more than one
month, print last month you were hospitalized.
NOTE: If needed, use the “REMARKS” section on side 2 of the form.
If you need more room to answer questions l.b., 5.b. and/or 6.b., or
Remarks
there are any other facts or statements you want us to consider, place
Section
an “X” in the box and write in this section. If necessary, use an extra
piece of paper.
Please sign the report form as you usually sign your name. Please
Signature, Date
provide a telephone number where you can be reached during the day.
and Telephone
Sections
Printed on Recycled Paper
FORM SSA-455-OCR-SM (10-2013)
4
*
DATE:
Disability Update Report
FORM APPROVED
Social Security Administration, P.O. Box
, Wilkes-Barre. PA 18767-
OMB NO. 0960-0511
PAYEE’S NAME AND ADDRESS
REPORT PERIOD
From:
To The Present
BENEFICIARY
TELEPHONE NUMBER
CLAIM NUMBER
PSC:
Please be sure to use black ink or a #2 pencil to print your answers. Also, read the enclosed instructions
before completing the form. Finally, remember that when answering the questions, the “REPORT PERIOD” for
to the present. If you have any
which we need information about you is from
questions, call 1-800-772-1213 or TTY for the hearing impaired at 1-800-325-0778.
1.
a. Since
have you worked for someone
YES
NO
or been self-employed?
b. If you answered “YES” to 1.a., please complete the information below.
WORK BEGAN
WORK ENDED
MONTHLY EARNINGS
Month
Year
Month
Year
Dollars Only, No Cents
Most
Recent
$
,
1.
Work
$
,
2.
$
,
3.
2.
Have you attended any school or work training program(s)
YES
NO
since
?
3.
Since
to the present...(Please place an ‘X’ in one box only):
my doctor and I
my doctor
my doctor
have not discussed
told me I
told me I
whether I can work.
cannot work.
can work.
4.
Place an “X” in only one box which best describes your health
now as compared to
.
BETTER
SAME
WORSE
Form SSA-455-OCR-SM (10-2013)
Continued on the Reverse
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